Index Metacarpophalangeal Joint Research Articles

Does Preservation of Metacarpophalangeal Joint Vascularity Protect Against Physeal Arrest in Index Finger Pollicization?

To determine whether preservation of blood supply to the index metacarpophalangeal joint decreases the rate of physeal arrest. A retrospective review of 41 pollicized digits in 35 patients with 2-year minimum radiographic follow-up was conducted at a single institution. Other complications evaluated included nonunion at the pollicized digit base and clinical instability at the new carpometacarpal joint. Findings were compared to historical controls, which were performed by our group prior to routine identification and sparing of the metacarpophalangeal joint blood supply. No other modifications to surgical technique were made between the previous and current patient cohorts. Two pollicized digits in two different patients had radiographic evidence of physeal arrest, one of which was partial and the other complete, for an arrest rate of 4.9%. This was significantly less than the arrest rate in our historical cohort of 24.7% (21 of 85 patients). Five patients did not have radiographic bony union at the base of the index metacarpal, but only one patient had clinical instability at the new carpometacarpal joint. Significantly fewer patients who underwent index finger pollicization with preservation of the metacarpophalangeal joint blood supply went on to develop physeal arrest when compared to patients who underwent pollicization prior to adoption of this technique. This finding suggests that sparing of the physeal blood supply is preventative against proximal phalanx physeal arrest. Therapeutic IV.

Anatomic relationship of extensor indicis propius and extensor digitorum communis: Implications for tendon transfer.

The extensor indicis proprius (EIP) tendon is a frequently used donor for a variety of tendon transfers, most commonly for reconstruction of the extensor pollicis longus (EPL). EIP is known to have frequent anatomic variants including split tendons and variations in tendon arrangement. To characterize the anatomy of the EIP at the level of the extensor retinaculum, where tendon harvest is often performed, and share our preferred technique for EIP to EPL transfer. Twenty-nine fresh-frozen cadaveric forearms without history of forearm or hand injury or surgery were dissected. Tendon circumference and relationship of the EIP and extensor digitorum communis to the index (EDCI) at the metacarpophalangeal (MCP) joint and the distal extensor retinaculum were recorded. Distance from the distal extensor retinaculum to the EIP myotendinous junction was measured. EIP was ulnar to the EDCI in 96.5% of specimens (28/29) at the distal edge of the extensor retinaculum. In the remaining specimen, EIP was volar to EDCI. Tendon circumference at the distal extensor retinaculum averaged (9.3 mm ± 1.7 mm) for EDCI and 11.1 mm (± 2.7 mm) for EIP (P = 0.0010). The tendon circumference at the index MCP joint averaged 11.0 mm (± 1.7 mm) for EDCI and 10.6 mm (± 2.1 mm) for EIP (P = 0.33). EIP had a greater circumference in 76% (22/29) of specimens at the distal extensor retinaculum whereas EIP had a greater circumference in only 31% (9/29) of specimens at the MCP joint. The EIP tendon is frequently ulnar to and greater in circumference than the EDCI at the distal extensor retinaculum, which can be taken into consideration for tendon transfers involving EIP.

Neglected Radial Collateral Ligament Rupture: Rare Case Report

Introduction : Rupture of the Radial Collateral Ligament (RCL) of the index metacarpophalangeal (MCP) joint is mostly related to acute local mechanical causes, which severely affect the stability of the MCP joint. Radial collateral ligament (RCL) injuries account for 10-40% of collateral ligament injuries of the thumb metacarpophalangeal joint.ere, we present an extremely rare case of chronic RCL injury.
 Patient Concern : Pain in the thumb of the right hand accompanied by weakness when trying to grasp something. Complaints are not accompanied by swelling. Patient said 2 years ago had an accident. Thumb at right hand is said to be swollen and shifting.
 Diagnosis : Based on the combination of physical examination, X-ray, and ultrasonic and magnetic resonance imaging, the patient was diagnosed with Radial Collateral Ligament rupture. Eventually, intra-operative findings confirmed the diagnosis.
 Intervention : Patient was underwent ligament reconstruction using a Palmaris Longus tendon graft.
 Conclusion : Favorable results suggest that the free tendon graft using Palmaris Longus is a suitable, safe, and technically feasible procedure for the operative treatment of chronic instability of the thumb metacarpophalangeal joint after radial hyperadduction trauma and complete rupture or deinsertion of the radial collateral ligament.

Complex Dorsal Dislocation of the Metacarpophalangeal Joint: A Case Report and Comprehensive Review

Complex dorsal dislocations of the metacarpophalangeal joint are usually a complication of hyperextension injury and are irreducible to closed maneuvers. The volar plate displaced between the dorsum of the metacarpal head and the volar base of the proximal phalanx is the obstacle that prevents reduction. While the pathophysiology of complexity is relatively clear, such injuries are uncommon and reduction requires experience. We describe a case of complex fracture dislocation of the index metacarpophalangeal joint with a review of the literature on relative anatomy and treatment armamentarium.

Reactive arthritis (ReA) following the first dose of Covid-19 vaccine; A case report.

Introduction: The development of vaccination against COVID-19 infection was a promising step during the battle against this pandemic; however, some vaccines were associated with some complications starting with just flu-like symptoms up to anaphylaxis; of the reported complications is joints pain. Here, we report a case who developed reactive arthritis (ReA) after receiving the first dose of the Pfizer-BioNTech Covid-19 vaccine. Case presentation: A healthy 54 years old male with no previous history of any medical condition was presented with bilateral hand and bilateral knee pain after one week of receiving his first dose of Pfizer-BioNTech Covid-19 vaccine. Clinical examination revealed swelling, tenderness, and erythema over the right index metacarpophalangeal joint and the medial aspect of the right knee. Radiographs of the hand and knee were normal. Laboratory investigations were within normal values except for an elevated ESR (15 mm/hr.) and a positive CRP titer of 48 mg/l. The symptoms entirely resolved after two weeks of non-steroidal anti-inflammatory medications. Conclusions: Although rare, however, ReA could be presented as a complication of Covid-19 vaccination, and physicians should be aware of the possibility of its occurrence.

Traumatic index extensor tendon attenuation mimicking closed tendon rupture: two case reports

BackgroundWhile some traumatic closed index extensor tendon ruptures at the musclotendinous junction have been previously reported, closed index extensor tendon pseudorupture due to intertendinous attenuation is exceedingly rare with only one case report of a gymnastics-related sports injury in the English literature. Herein, we report two non-sports injury related cases of traumatic index extensor tendon attenuation mimicking closed tendon rupture, including the pathological findings and intraoperative video of the attenuated extensor indicis proprius tendon.Case presentationA 28-year-old man and a 30-year-old man caught their hands in a high-speed drill and lathe, respectively, which caused a sudden forced flexion of their wrists. They could not actively extend the metacarpophalangeal joints of their index fingers. Intraoperatively, although the extensor indicis proprius and index extensor digitorum communes tendons were in continuity without ruptures, both tendons were attenuated and stretched. The attenuated index extensor tendons were reconstructed either with shortening by plication or step-cut when the tendon damage was less severe or, in severely attenuated tendons, with tendon grafting (ipsilateral palmaris longus) or tendon transfer. Six months after the operation, the active extension of the index metacarpophalangeal joints had recovered well.ConclusionsTwo cases of traumatic index extensor tendon attenuation were treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer. We recommend WALANT (wide-awake local anesthesia and no tourniquet) in the reconstruction surgery of index extensor tendon attenuation to determine the appropriate amount of tendon shortening or optimal tension for tendon grafting or transfer. Intraoperative voluntary finger movement is essential, as it is otherwise difficult to judge the stretch length of intratendinous elongation and extent of traumatic intramuscular damage affecting tendon excursion.

Anatomical Study of the First Dorsal Interosseous Tendon for its Use as a Plasty of the Radial Collateral Ligament of the Index Metacarpophalangeal Joint

Purpose The authors present an anatomical study to justify the use of the distal portion of the tendon of the first dorsal interosseous muscle (FDIM) for the repair of the chronic rupture of the radial collateral ligament (RCL) of the metacarpophalangeal joint of the index finger. Methods Ten hands of cryopreserved specimens were used and thawed at room temperature for dissection with optical magnification. Five were hands of women, and their ages ranged from 46–96 years (mean: 72.8), and 8 corresponded to the right hand. Results The length of the tendon of the FDIM ranged from 20 to 40 mm (mean: 25 mm). The length of the RCL ranged from 14 to 24 mm (mean: 18.2 mm). The difference between both structures of the same specimen averaged 6.8 mm (2–16 mm). Therefore, the dorsal portion of the tendon of the FIDM is always at least 2 mm longer than the length of the RCL. Conclusions In conclusion, this is a simple technique that allows the surgeon to perform a plasty of the RCL without sacrificing another tendon in the absence of the palmaris longus, which is more commonly used for this purpose. The maintenance of its distal insertion may also help in the revascularization of the repaired area.

Accuracy and Validity of Goniometer and Visual Assessments of Angular Joint Positions of the Hand and Wrist

To compare goniometric and visual assessments of angular hand joint and wrist joint positions measured by board-certified hand surgeons and certified hand therapists. We hypothesized that visual estimation would be similar to the goniometric measurement accuracy of digital and wrist joint positions. The wrist, index finger metacarpophalangeal (MCP) joint, and index finger proximal interphalangeal (PIP) joint were evaluated in different positions by 40 observers: 20 board-certified hand surgeons and 20 certified hand therapists. Each observer estimated the position of the wrist, index MCP joint, and index PIP joint of the same volunteer, who was positioned in low-profile orthoses to reproduce predetermined positions. Following visual estimation, the participants measured the same joint positions using a goniometer. The control measurement was digitally determined by a radiologist who obtained radiographs of the hand and wrist positions in each orthosis. Observers were blinded to the results of control measurements. When considering all joints at all positions, neither visual assessments nor goniometer assessments were consistently within ± 5° of the measurements obtained on control radiographs. When considering individual joints, goniometer measurements were significantly closer to control radiograph measurements than the visual assessments for all 3 PIP joint positions. There was no difference for the measurements at the wrist or for 2 of the 3 MCP joint positions. Significant differences between surgeon and therapist joint angle measurements were not observed when comparing visual and goniometer assessments to radiograph controls. Compared with radiograph measurements, neither visual nor goniometer assessment displayed high levels of accuracy. On average, visual assessment of the angular positions of the index MCP and wrist joint were as accurate as the goniometer assessment, whereas goniometer assessment of the angular position of the PIP joint was more accurate than visual assessment. There was a relatively high degree of between-observer variability in measurements, and therefore, no one person's measurements could be consistently relied upon to be accurate. Diagnostic II.

A Case of Psoriasis Accompanied by Systemic Lupus Erythematosus.

Dear Editor: The pathologic mechanisms of systemic lupus erythematosus (SLE) and psoriasis are different: psoriasis is caused by systemic inflammatory reaction from mainly Th1 cell activation, whereas SLE is caused by Th2 cell-related abnormalities. Cases of generalized psoriasis caused by the anti-CD20 monoclonal antibody rituximab and cases of aggravation of SLE after anti-tumor necrosis factor α biologics have been reported, suggesting the immunopathologic mechanisms of these two diseases are opposite1,2. However, we experienced a case of psoriasis accompanied by SLE. A 32-year-old woman had erythematous scaly macules and patches on the trunk, inguinal area, and forehead starting one year ago (Fig. 1A, B). Medical history included arthralgia progressing since one year ago, starting from the left third finger and spreading to all fingers, wrists, toes, ankles, knees, and hips (Fig. 2A). Serologic findings were as follows: anti-SSA/Ro Ab(+), anti-Smith Ab(+), fluorescent antinuclear antibody(+), and speckled pattern. She also presented with a malar rash starting 3 months ago. On the basis of clinical and serologic findings, she was diagnosed with SLE. She was prescribed methotrexate 15 mg weekly, hydroxychloroquine 400 mg, prednisolone 5 mg, and nonsteroidal anti-inflammatory drugs, and the pain seemed to abate. To evaluate skin lesions, the forehead lesion was subjected to biopsy. Histopathologic findings were consistent with psoriasis (Fig. 1C). The skin lesions responded to topical vitamin D3 analogue and topical steroid. Arthritis was evaluated by radiography; the findings of the left hip, bilateral middle fingers, and right index finger were suggestive of psoriatic arthritis, indicating that psoriasis preceded SLE (Fig. 2B). Th17 cells can be associated with the pathogenesis of various autoimmune and inflammatory diseases by producing several effector molecules. Interleukin (IL)-17 is a potent proinflammatory cytokine produced by highly activated Th17 cells and is well known to play a major role in maintaining chronic inflammation in psoriasis. Actually, skin biopsies from patients with psoriasis exhibit high IL-17, IL-22, and IL-23 expressions3. IL-22, one of the effector molecules produced by Th17 cells, induces antimicrobial agents and β-defensins in keratinocytes and promotes epidermal hyperplasia4. This cytokine is also known to be essential for the immune barrier function of epithelial cells. Recent evidence indicates IL-17 also plays a role in the pathogenesis of SLE. Patients with SLE have higher serum levels of IL-17 and IL-23 than healthy controls3,5. Interestingly, plasma IL-17 levels are correlated with SLE disease activity5. In animal models, IL-17 is related not only to T cell-mediated tissue injury, but also to the production of pathogenic autoantibodies. In the presence of IL-17, SLE-derived B cells increase anti-DNA production5. However, the exact function of IL-17 that leads to SLE remains unknown. Besides IL-17, IL-21 produced by Th17 cells causes CD8+ T cell proliferation and induces B cell differentiation4. In summary, we report a case of psoriasis accompanied by SLE. We propose the Th17 cell-mediated immune pathway is common to both diseases. This case suggests the potential utility of treating SLE with Th17 cell-targeting agents. Fig. 1 (A) Erythematous scaly patches on the forehead. (B) An erythematous scaly patch on the inguinal area. (C) Regular elongation of rete ridges, parakeratosis, and mononuclear cell infiltration in the epidermis (HE inset: ×100). ... Fig. 2 (A) Swollen proximal interphalangeal joints on bilateral third fingers. (B) Radiograph showing marginal erosion at the right third proximal interphalangeal joint, small bony proliferation at the right index metacarpophalangeal joint, and suspicious erosion ...

Anatomy of the Radial Collateral Ligament of the Index Metacarpophalangeal Joint

To describe the origin and insertion of the radial collateral ligament (RCL) of the index metacarpophalangeal (MP) joint, relative to the MP joint line and other landmarks readily discernible intraoperatively. We dissected 17 fresh-frozen human cadaveric index fingers. We removed all overlying soft tissue from the MP joint except for the proper RCL. We dissected the RCL from its original insertion under loupe magnification while concurrently marking the ligamentous origin and insertion points. We measured distances of these points in relation to the bony landmarks (dorsal, articular, and volar surfaces) using digital photo analysis. The same observer recorded all measurements to reduce systematic error. The center of the metacarpal attachment of the RCL was located 5.4 ± 1.1 mm from the dorsal border of the metacarpal, 8.0 ± 2.2mm from the volar border of the metacarpal, and 10.3 ± 3.2mm from the articular surface of the MP joint. The total width and height of the metacarpal origin site were 5.8 ± 1.6 and 6.4 ± 1.4 mm, respectively. The center of the proximal phalanx attachment of the RCL was located 6.8 ± 1.4 mm from the dorsal border of the proximal phalanx, 5.7 ± 0.9 mm from the volar border of the proximal phalanx, and 4.4 ± 0.8mm from the articular surface of the MP joint. The total width and height of the phalangeal origin site were 5.0 ± 1.1 and 5.7 ± 0.9 mm, respectively. Our study defines the anatomic origin and insertion of the RCL of the index MP joint in relation to landmarks that are identifiable during surgery. We believe this information will be useful to surgeons when repairing or reconstructing the RCL, allowing for recreation of normal RCL anatomy.

Giant cell tumour of bone: Reconstruction of the index metacarpophalangeal joint with an osteochondral graft from the lateral femoral condyle

We describe the successful reconstruction of the index finger metacarpophalangeal joint with an osteochondral autograft from the lateral femoral condyle following failed curettage and cementation of a giant cell tumour of the proximal phalanx base. At the 2-year follow-up, a good functional outcome was noted with 0-80° range of motion of the metacarpophalangeal joint and no clinical or radiographic evidence of tumour recurrence.

The Fate of the Index Metacarpophalangeal Joint Following Pollicization

To characterize the complications that occur at the index metacarpophalangeal (MCP) joint following pollicization and to identify the blood supply of the index MCP joint. Eighty-five pollicized digits in 74 patients (1974-2007) were followed after surgery and had documented clinical examinations and radiographs to evaluate physeal arrest, nonunion at the pollicized digit base, and instability of the new carpometacarpal joint at a minimum of 2 years following surgery. Proximal phalanx physeal arrest was the most common complication. Radiographic nonunion at the juncture of the index metacarpal head and base occurred with and without instability. Twenty-one of 85 pollicized digits showed radiographic evidence of physeal arrest, 12 of which were complete and 9 partial. No clinical factor was found to significantly correlate with a physeal arrest, although the 9 patients with the diagnosis of Holt-Oram syndrome trended toward a higher percentage, with 6 digits in 5 patients with Holt-Oram syndrome showing this complication. Twenty pollicized MCP joints did not have bony union to the base of the index metacarpal, but only 3 were clinically unstable and required surgical stabilization. Ten pollicized digits developed some degree of instability and subluxation at the new carpometacarpal joint, but only one required surgical intervention. In recent cases, a search for the blood supply to the MCP joint has demonstrated a consistent vessel deep to the interosseous muscles that arborizes on the volar metacarpal neck. Our surgical technique has evolved to preserve this vessel whenever possible. Our complications are most likely due to technical factors. Careful dissection of the index MCP joint during pollicization should help reduce physeal growth arrest. Patients with Holt-Oram syndrome might have an increased risk of growth arrest. However, the majority of patients did not require secondary surgery and have good function. Therapeutic IV.

Juxta-articular myxoma of the palm.

We present a case of juxta-articular myxoma of the hand in a 63-year-old man with an enlarging mass over the palmar radial aspect of the index metacarpophalangeal joint. Usually seen in men, this benign soft tissue tumour is normally found around large joints. To our knowledge this is the first reported case in the hand.

Effects of the index finger position and force production on the flexor digitorum superficialis moment arms at the metacarpophalangeal joints — a magnetic resonance imaging study

BackgroundThe purpose of this study was to use magnetic resonance imaging to measure the moment arm of the flexor digitorum superficialis tendon about the metacarpophalangeal joint of the index, middle, ring, and little fingers when the position and force production level of the index finger was altered. A secondary goal was to create regression models using anthropometric data to predict moment arms of the flexor digitorum superficialis about the metacarpophalangeal joint of each finger. MethodsThe hands of subjects were scanned using a 3.0T magnetic resonance imaging scanner. The metacarpophalangeal joint of the index finger was placed in: flexion, neutral, and extension. For each joint configuration subjects produced no active force (passive condition) and exerted a flexion force to resist a load at the fingertip (active condition). ResultsThe following was found: (1) The moment arm of the flexor digitorum superficialis at the metacarpophalangeal joint of the index finger (a) increased with the joint flexion and stayed unchanged with finger extension; and (b) decreased with the increase of force at the neutral and extended finger postures and did not change at the flexed posture. (2) The moment arms of the flexor digitorum superficialis tendon of the middle, ring, and little fingers (a) did not change when the index metacarpophalangeal joint position changed (P>0.20); and (b) The moment arms of the middle and little fingers increased when the index finger actively produced force at the flexed metacarpophalangeal joint posture. (4) The moment arms showed a high correlation with anthropometric measurements. InterpretationMoment arms of the flexor digitorum superficialis change due to both changes in joint angle and muscle activation; they scale with various anthropometric measures.

Influence of Index Finger Proximal Interphalangeal Joint Arthrodesis on Precision Pinch Kinematics

To evaluate the impact of proximal interphalangeal (PIP) joint arthrodesis on the kinematics of precision pinch. Eleven healthy subjects performed index finger-thumb pinch motions under 4 conditions: unrestricted thumb and index finger (CONTROL) and fusion of the PIP joint of the index finger in flexion of 30° (PIP30), 40° (PIP40), and 50° (PIP50). Fusion was simulated with metallic splints. Kinematics of the thumb and index finger were recorded with a motion capture system. Proximal interphalangeal joint fusion at 30°, 40°, and 50° restricted maximal pinch span between the thumb tip and index finger tip by 6%, 10%, and 14%, respectively. At the time of pulp contact, PIP fusion led to an increase in index metacarpophalangeal joint flexion angle for the PIP30 condition and an increase in variability of thumb tip location for the PIP50 condition. Furthermore, the dynamic coordination between joint angles throughout the movement was affected by PIP fusion. This study reports impairment in the kinematics of precision pinch associated with index finger PIP joint fusion. A PIP joint fusion at 40° to 50° leads to a more natural precision pinch posture, but it restricts the aperture and reduces pinch precision.

Motor somatotopy of extensor indicis proprius and extensor pollicis longus

After tendon transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL), rehabilitation is initiated to enhance motor cortex reorganization. However, patients have been described showing thumb extension immediately after the tendon transfer. At cortical level, no evidence supports either of these assumptions. We noninvasively investigated motor cortical source locations of EIP and EPL muscles. Magnetoencephalography was used to identify motor somatotopic map in healthy right-handed participants, who performed voluntary extension at index metacarpophalangeal joint and thumb interphalangeal joint. Motor cortical representation of EIP was more medial than cortical representation of EPL, with mean Euclidean distance of 15.4±2.7 mm. Motor somatotopic map of EIP/EPL that was obtained by magnetoencephalography supports 'functional somatotopy' representation of the finger in primary motor cortex.

Acute Calcific Tendinitis

A 56-year-old woman presented to the emergency department with a 3-day history of severe pain in and loss of movement of her right index finger. She reported that for the previous 2 months, she had noted a small, tender lump, with no progression in size, near the finger joint. Marked palmar erythema and a tender, firm swelling overlying the index metacarpophalangeal joint were noted (Panel A). Initially, a flexor-sheath infection was suspected, and antibiotics were administered. However, radiography showed a calcified mass within the flexor digitorum tendon (Panel B, arrow), and calcific tendinitis was diagnosed. Calcific tendinitis may be an . . .

Rupture of the Radial Collateral Ligament of the Index Metacarpophalangeal Joint: Diagnosis and Surgical Treatment

Rupture of the Radial Collateral Ligament of the Index Metacarpophalangeal Joint: Diagnosis and Surgical Treatment

Rupture of the Radial Collateral Ligament of the Index Metacarpophalangeal Joint: Diagnosis and Surgical Treatment

To report the diagnosis and results of 12 surgically treated cases of isolated radial collateral ligament (RCL) tears of the index finger (IF) metacarpophalangeal (MCP) joint. Between 1996 and 2002, there were 12 patients who were diagnosed with a tear of the index RCL based on clinical evaluation, had surgical treatment, and were followed up for a minimum of 23 months. All 12 patients sustained complete, full-thickness tears. Three patients chose immediate surgical treatment, and 9 patients failed an initial trial of conservative treatment. Surgical repair was performed because of pain, swelling, tenderness, and instability, and a suture anchor was used in all repairs. Intraoperative findings correlated with preoperative magnetic resonance imaging regarding to the site of the tear and the presence of associated injuries. Range of motion, grip strength, and lateral pinch strength were recorded. Patients were questioned regarding satisfaction with their treatment and with their ability to return to work and/or sporting activities. The RCL was avulsed more commonly from the metacarpal (7 patients) than from the proximal phalanx (5 patients). There were no midsubstance tears. All patients reported resolution of pain, ability to return to activities of daily living or sporting activities, and satisfaction with treatment. The mean IF MCP joint arc of motion was 80 degrees , with a mean extension and flexion of 0 degrees and 80 degrees , respectively. There was no extensor lag and no laxity to stress in any of the repaired ligaments. The mean grip strength expressed as a percentage of the injured/noninjured side was 111%. The mean lateral pinch expressed as a percentage of the injured/noninjured side was 112%. On the basis of this study, IF RCL ruptures can be treated successfully with surgical repair.

Radial Collateral Ligament Injury of the Index Metacarpophalangeal Joint: An Underreported but Important Injury

To present the results of various treatment modalities based on injury grade of radial collateral ligament (RCL) injuries to the index metacarpophalangeal (MP) joint. Fourteen patients were evaluated (4 male, 10 female) with RCL injuries to the index MP joint. We defined injuries as Grade 1 (tenderness over RCL, no instability), grade 2 (laxity compared to the contralateral digit with a definite endpoint), or grade 3 (laxity without endpoint). Early presentation is defined as less than four weeks and late greater than four weeks. The average follow up was 24 months. Grade I-II injuries seen early (4 patients) treated with 4-6 weeks splinting had excellent results (normal ROM, stable pinch, pain free). There were no Grade I-II injuries seen late. Of Grade III injuries seen early (2 patients), attempted treatment in a removable splint was unsuccessful secondary to patient noncompliance; subsequently requiring primary repair of the collateral ligament which resulted in good outcomes. No Grade III injury seen early had attempted treatment in a cast. Eight patients presented late with Grade III injuries (4 elected for surgical intervention, 4 for nonsurgical management) and all had fair or poor outcomes. The significance of this injury remains underestimated and requires a high index of suspicion. Stable injuries seen early should be treated with prompt immobilization. Casting may be more effective than a removable splint. Grade III injuries seen early could possibly be treated with cast immobilization though close follow up is mandatory as surgical repair may be necessary in the high demand hand. All Grade III injuries treated late yielded fair to poor results requiring tendon reconstruction or fusion with significant alteration in hand function.