What is the treatment for a partial thickness insertional tear of the radial collateral ligament (RCL) of the first index proximal interphalangeal (PIP) joint?

Treatment for Partial Thickness Insertional Tear of Radial Collateral Ligament of the First Index PIP Joint

Conservative management with immobilization for 4-6 weeks is the recommended first-line treatment for partial thickness insertional tears of the radial collateral ligament (RCL) of the index finger proximal interphalangeal (PIP) joint. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Imaging studies:

  • MRI is the preferred imaging modality for accurate assessment of collateral ligament injuries 2
  • Ultrasound can be considered as an alternative with comparable accuracy for partial thickness tears (sensitivity 77%, specificity 94%) 2
  • MR arthrography may provide better visualization if there is uncertainty about the extent of the tear 2

• Clinical assessment:

  • Assess for tenderness over the RCL
  • Evaluate joint stability with stress testing
  • Compare with contralateral digit

Treatment Algorithm

Grade-Based Treatment Approach

1. Grade 1-2 injuries (partial tears with minimal or no instability):

   • Early presentation (<4 weeks):
     • Immobilization with splinting for 4-6 weeks 1
     • Consider casting rather than removable splint for better compliance
     • Protect the joint from radial stress

2. Grade 3 injuries (complete tears with instability):

   • Early presentation (<4 weeks):
     • Surgical repair may be necessary, especially in high-demand hands 1
     • Primary repair using suture anchors shows good outcomes 3

3. Late presentation (>4 weeks):

   • Poorer outcomes regardless of treatment approach 1
   • May require tendon reconstruction or fusion in severe cases

Conservative Management Protocol

• Immobilization:

  • Custom-made thermoplastic splint or cast
  • PIP joint positioned in slight flexion (10-20°) to avoid hyperextension
  • Duration: 4-6 weeks for partial tears

• Rehabilitation after immobilization:

  • Gradual range of motion exercises
  • Strengthening exercises for intrinsic muscles
  • Buddy taping during activities for additional support

Special Considerations

• Risk factors for poor outcomes:

  • Delayed presentation (>4 weeks)
  • Complete tears (Grade 3)
  • Poor compliance with immobilization
  • High-demand activities requiring pinch or grip strength

• Surgical indications:

  • Failed conservative management
  • Complete tears with instability
  • Stener-like lesions where soft tissue interposition prevents healing 4
  • High functional demands on the hand

Prognosis

• Grade 1-2 injuries treated early with proper immobilization have excellent outcomes (normal ROM, stable pinch, pain-free) 1
• Grade 3 injuries or delayed treatment often result in fair to poor outcomes 1
• Untreated injuries may lead to chronic instability, swan neck deformity, or degenerative changes 5

Prevention of Recurrence

• Technique modification for occupational or sports activities
• Strengthening exercises for intrinsic hand muscles
• Temporary buddy taping during return to activities

Early diagnosis and appropriate immobilization are critical for successful outcomes in partial thickness RCL tears of the index PIP joint. The American College of Radiology guidelines support the use of MRI or ultrasound for accurate diagnosis 2, while treatment outcomes strongly favor early intervention with proper immobilization for partial tears 1.