The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 14

Scientific Articles | July 20, 2011

Changes in Shape and Length of the Collateral and Accessory Collateral Ligaments of the Metacarpophalangeal Joint During Flexion

Toshiyuki Kataoka, MD¹; Hisao Moritomo, MD, PhD¹; Junichi Miyake, MD¹; Tsuyoshi Murase, MD, PhD¹; Hideki Yoshikawa, MD, PhD¹; Kazuomi Sugamoto, MD, PhD¹

¹ Departments of Orthopaedic Surgery (T.K., H.M., J.M., T.M., and H.Y.) and Orthopaedic Biomaterial Science (K.S.), Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka 565-0871, Japan. E-mail address for T. Kataoka: kataoka@qk9.so-net.ne.jp. E-mail address for H. Moritomo: moritomo@ort.med.osaka-u.ac.jp

View Disclosures and Other Information

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this work are available with the online version of this article at jbjs.org.

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Investigation performed at the Department of Orthopaedic Surgery, Osaka University, Osaka, Japan

J Bone Joint Surg Am, 2011 Jul 20;93(14):1318-1325. doi: 10.2106/JBJS.J.00733

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Abstract

Background:

Although the collateral and accessory collateral ligaments of the metacarpophalangeal joint contribute to the stability of this joint, the functional role of the various portions of these ligaments during flexion is unclear. We investigated changes in the three-dimensional shape and length of the collateral and accessory collateral ligaments during flexion to determine how each portion stabilized the metacarpophalangeal joint.

Methods:

Twelve fingers from three embalmed cadavers were examined. The origin and the insertion point of the dorsal, middle, and volar portions of the radial and the ulnar collateral ligament and of the radial and the ulnar accessory collateral ligament were precisely identified. Microcomputed tomograms were obtained at 10° intervals during passive flexion from 0° to 80°. We created three-dimensional models of the metacarpal, the proximal phalange, and the paths of the twelve ligament portions. Finally, we calculated the change in the shape and length of the path of each ligament portion during flexion.

Results:

The region of contact between each collateral ligament and the lateral edge of the metacarpal gradually lengthened during flexion of the joint, and the ligament gradually stretched to pass around the convex radial or ulnar surface of the metacarpal head. In contrast, each accessory collateral ligament curved around the volar tubercle of the metacarpal head at all flexion angles. The length of the volar portion of each collateral ligament and the length of the dorsal and middle portions of each accessory collateral ligament underwent little change during flexion. However, the lengths of the dorsal and middle portions of each collateral ligament increased significantly during flexion, and the length of the volar portion of each accessory collateral ligament decreased significantly.

Conclusions:

The collateral and accessory collateral ligaments can each be functionally divided into three portions—dorsal, middle, and volar. The volar portion of each collateral ligament and the dorsal and middle portions of each accessory collateral ligament are nearly isometric, the dorsal and middle portions of each collateral ligament become taut only in flexion, and the volar portion of each accessory collateral ligament becomes taut only in extension.

Clinical Relevance:

The results of the current study provide a good starting point for future research on the pathology of volar subluxation of the metacarpophalangeal joint.

Figures in this Article

Introduction

The metacarpophalangeal joint is condylar, allowing motion in three separate planes—flexion-extension, abduction-adduction, and axial rotation¹. The stabilizers of the metacarpophalangeal joint include the two collateral ligaments and the two accessory collateral ligaments¹. The collateral ligaments have been described as major stabilizers of the joint and are tight in flexion, thus limiting lateral motion, but lax in extension, thus permitting a greater arc of lateral motion^1,2. The accessory collateral ligaments have been considered secondary stabilizers, forming a sling that holds the volar plate under the head of the metacarpal³. How the collateral and accessory collateral ligaments function cooperatively in stabilizing the metacarpophalangeal joint remains unclear.

The collateral and accessory collateral ligaments originate from the dorsolateral aspect of the metacarpal head and insert on the lateral aspect of the base of the proximal phalanx and on the volar plate, respectively. The collateral and accessory collateral ligaments have been reported to change from a straight to a curved configuration as they curve around the volar tubercle of the metacarpal head during flexion⁴, but this change in shape has not been investigated biomechanically.

Minami et al. studied the lengths of the collateral ligaments of the metacarpophalangeal joint of the index finger during flexion with use of a biplanar radiographic technique⁵. However, they measured the distance between markers placed at the origin and the insertion of the ligament, which may not provide an accurate length if the path of the ligament curves around the metacarpal head. More recently, researchers have been able to measure the functional length of a ligament with use of three-dimensional motion analysis, by tracing the shortest path in a three-dimensional space containing osseous obstacles^6-10. We have used this technique to study the change in three-dimensional shape of the ligaments of the metacarpophalangeal joint during flexion and to calculate the functional length of each ligament by constraining its path to avoid penetrating the bones. We designed the current study to investigate the change in shape and length of each collateral and accessory collateral ligament during flexion, with use of this technique, in order to understand how the portions of the collateral and accessory collateral ligaments stabilize the metacarpophalangeal joint.

Materials and Methods

Subject Preparation and Image Acquisition

Four fingers (excluding the thumb) from each of three embalmed cadavers were examined. The mean age at the time of death was eighty-four years (range, seventy-four to ninety-four years). No apparent pathological lesion was identified in any of the metacarpophalangeal joints. Specimens were disarticulated at the carpometacarpal and proximal interphalangeal joints. The soft tissue was removed carefully to preserve the capsuloligamentous tissue around the metacarpophalangeal joint. Each collateral and accessory collateral ligament was treated as consisting of three portions (dorsal, middle, and volar); thus, twelve ligament portions were identified per finger. A metal marker (0.7 mm in diameter) was placed at the origin and at the insertion point of each of the twelve ligament portions. The six insertion points of the radial and ulnar accessory collateral ligament portions were identified by inserting the metal marker into the volar plate. Three-dimensional computed tomography scanning was performed at 10° intervals during passive flexion from 0° to 80° with use of a microcomputed tomography scanner (SMX-100CT-SV; Shimadzu, Kyoto, Japan) with an image slice thickness of 0.095 mm.

Creation of a Three-Dimensional Model of the Metacarpal and the Proximal Phalanx

The surface contour of each individual bone was segmented (extracted from the images and identified with a specific bone) semiautomatically. A three-dimensional model of the surface of the cortex was then constructed¹¹ with use of original software based on the Visualization Toolkit (Kitware, Clifton Park, New York). Surface-based registration was performed to match the bone surface of the metacarpal or the proximal phalanx at one position with that of the metacarpal or the proximal phalanx at another position. Visualization of the geometrical model of each bone was performed with use of software developed in our laboratory (Orthopedics Viewer; Osaka University, Osaka, Japan).

Creation of Three-Dimensional Ligament Paths and Measurement of Their Change in Length

The origin and the insertion of each ligament portion were plotted on the three-dimensional bone model. We then connected these points to model the path of each of the twelve ligament portions (i.e., the dorsal portion, middle portion, and volar portion of the radial collateral, ulnar collateral, radial accessory collateral, and ulnar accessory collateral ligaments) in each finger at each flexion angle. The path of the ligament was modeled as the shortest possible path that avoided the osseous obstacles in the three-dimensional space, as proposed by Marai et al.¹². The method used to calculate the shortest path thereby took into account the fact that the ligament would curve around osseous prominences rather than running in a straight line from origin to insertion. We then calculated the three-dimensional length of the portion of the ligament during flexion of the metacarpophalangeal joint. In order to express how the ligament path curved around an osseous prominence, we defined the arc height as the distance between the apex of the curved arc of the path and the line directly connecting the origin and the insertion of the ligament (measured along a line perpendicular to the direct line) (Fig. 1). We also calculated the average arc height of each ligament by averaging the arc heights of the dorsal, middle, and volar portions of the ligament.

Fig. 1

A model of the metacarpophalangeal joint of the right index finger in 80° of flexion, viewed from the distal side of the metacarpal. The red path shows the volar portion of the radial collateral ligament. The yellow line is the line directly connecting the origin and insertion of the ligament. The arc height is defined as the distance between the apex of the ligament path and the line directly connecting its attachments.

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Measurement of the Width of the Osseous Contact Region

We measured the width of the inferred region of contact between the bones of the metacarpophalangeal joint during flexion with use of a proximity mapping method^13,14 in order to determine how osseous contact stabilized the joint in the abduction-adduction plane. A previously described custom program was used to determine the distance between the bones¹⁴. This program used the output file from the reconstructed three-dimensional model, which contains the position of each vertex of each of the individual triangles that form the surface of the reconstructed bone. The vertices of the triangles were used as discrete osseous landmarks and provided a starting point for estimating the minimum distance between bones. The algorithm calculated the distance from the vertex to each vertex of the other bone, then determined the minimum distance. A map showing the region in which the two bone surfaces were in close proximity (defined as ≤1.5 mm) was generated from the three-dimensional model of the metacarpal and the proximal aspect of the phalanx.

Statistical Analysis

All data were expressed as the mean and standard deviation. Repeated measurements were compared with use of analysis of variance. The significance of differences between mean values was calculated with use of a post hoc Bonferroni correction. The significance level was set at p < 0.05.

Source of Funding

There was no external funding source for this investigation.

Results

Anatomy of the Origin and Insertion of the Collateral and Accessory Collateral Ligaments (Fig. 2)

The origins of the radial and ulnar collateral ligaments were located just distal to the prominent lateral tubercle of the metacarpal head, with the volar portions originating almost at the apex of the tubercle (Fig. 3). The origins of the dorsal, middle, and volar portions of the radial collateral ligament were aligned obliquely from the volar and distal side to the dorsal and proximal side, whereas those of the ulnar collateral ligament were aligned more parallel to the longitudinal axis of the bone. The radial and ulnar collateral ligaments inserted on the volar half of the lateral aspect of the base of the proximal phalanx. The origins of the dorsal, middle, and volar portions of the radial accessory collateral ligament were aligned obliquely from the dorsal and distal side to the volar and proximal side, whereas the origins of the portions of the ulnar accessory collateral ligament were aligned more parallel to the longitudinal axis of the bone. The origins of the radial and ulnar accessory collateral ligaments were located just proximal to the origins of the radial and ulnar collateral ligaments. The dorsal, middle, and volar portions of the radial and ulnar accessory collateral ligaments were fan-shaped and inserted on the distal two-thirds of the lateral margin of the volar plate.

Fig. 2

Three-dimensional models of the metacarpal (A and B) and the proximal phalanx (C and D) of the index finger, showing the origins of the ligaments in a radiodorsal view (A) and an ulnodorsal view (B) and showing the insertions of the ligaments in a radioproximal view (C) and an ulnoproximal view (D). The blue, red, and green areas indicate the dorsal, middle, and volar portions of the ligament, respectively. Fiber bundles connect identically-lettered sites.

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Fig. 3

Three-dimensional models of the metacarpophalangeal joint of a representative right middle finger at 0°, 20°, 40°, 60°, and 80° of flexion, viewed from the dorsal side of the proximal phalanx. The three-dimensional paths of the dorsal (blue), middle (red), and volar (green) portions of the collateral ligaments are shown. The volar portion of each radial and ulnar collateral ligament (green) originates from the apex of the lateral tubercle. As the joint flexed, the portion of the radial and ulnar collateral ligaments in contact with the lateral edge of the metacarpal head gradually increased as the path of the ligament curved around the volar tubercle (arrows).

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Change in Shape of the Ligament Paths During Flexion

Animation of the metacarpophalangeal joint during flexion showed that the region of contact between each collateral ligament and the lateral edge of the metacarpal gradually increased as the joint flexed and that the ligament gradually stretched to pass around the convex radial or ulnar surface of the metacarpal head (Fig. 3). In particular, the path of the radial collateral ligament of the index finger curved markedly around the radial volar tubercle of the metacarpal head during flexion. Similarly, the path of the ulnar collateral ligament of the little finger curved markedly around the ulnar volar tubercle of the metacarpal head. The paths of the accessory collateral ligaments, in contrast, had a constant pattern of contact with the lateral edge of the metacarpal throughout the range of motion (Fig. 4), although the pattern differed between the two most radial and the two most ulnar fingers. The paths of the radial accessory collateral ligaments of the index and middle fingers curved around the radial volar tubercle of the metacarpal head, and the paths of the ulnar accessory collateral ligaments of the ring and little fingers curved around the ulnar volar tubercle of the metacarpal head.

Fig. 4

Three-dimensional models of the metacarpophalangeal joint of a representative right middle finger at 0°, 40°, and 80° of flexion of the metacarpophalangeal joint, viewed from the distal radial (A) and ulnar (B) sides. The three-dimensional paths of the dorsal (blue), middle (red), and volar (green) portions of the accessory collateral ligaments are shown. Note that the portion of the ligament in contact with the lateral edge of the metacarpal was relatively constant throughout flexion, as the paths curved around the volar tubercle of the metacarpal head (arrows) at all flexion angles.

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An increase in the mean arc heights of the radial collateral ligament of the index finger (from 0.6 ± 0.4 to 2.1 ± 0.6 mm, p < 0.05) and of the middle finger (from 0.3 ± 0.2 to 1.1 ± 0.4 mm, p < 0.05) occurred during flexion ( Fig. 5, A and B). An increase in the mean arc heights of the ulnar collateral ligament of the ring finger (from 0.4 ± 0.3 to 0.7 ± 0.5 mm, p < 0.05) and of the little finger (from 0.4 ± 0.4 to 0.9 ± 0.4 mm, p < 0.05) also occurred during flexion ( Fig. 5, C and D). The mean arc heights of the radial and ulnar accessory collateral ligaments did not change significantly during flexion (see Appendix).

Fig. 5

Bar graphs showing the arc heights (and standard deviation) of the radial collateral ligament (blue) and the ulnar collateral ligament (red) of the index finger (A), the middle finger (B), the ring finger (C), and the little finger (D) during flexion. The arc heights of the radial collateral ligaments of the index and middle fingers and of the ulnar collateral ligaments of the ring and little fingers increased significantly during flexion. *p < 0.05.

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Change in Ligament Length During Flexion

The mean length of the dorsal portion of the radial collateral ligament increased by 3.8 mm (from 6.8 ± 1.7 to 10.6 ± 1.7 mm, p < 0.05) during flexion, and the mean length of the middle portion increased by 2.0 mm (from 10.6 ± 2.0 to 12.6 ± 1.8 mm, p < 0.05). The volar portion of the radial collateral ligament underwent only a 0.1-mm change in mean length (from 14.3 ± 2.0 to 14.2 ± 1.7 mm, p = 0.99) during flexion ( Fig. 6, A). The mean length of the dorsal portion of the ulnar collateral ligament increased by 3.9 mm (from 6.3 ± 1.0 to 10.2 ± 1.3 mm, p < 0.05) during flexion, and the mean length of the middle portion increased by 2.0 mm (from 9.9 ± 1.2 to 11.9 ± 1.4 mm, p < 0.05). The mean length of the volar portion of the ulnar collateral ligament changed by only 0.1 mm (from 13.0 ± 1.5 to 13.1 ± 1.4 mm, p = 0.32) during flexion ( Fig. 6, B). There was no significant difference in the change in length of either the radial or the ulnar collateral ligament among the various fingers (see Appendix).

Fig. 6

Line graphs showing the change in the lengths of the radial collateral ligament (A), ulnar collateral ligament (B), radial accessory collateral ligament (C), and ulnar accessory collateral ligament (D) of the metacarpophalangeal joint during flexion. Significant changes were observed in the dorsal and middle portions of the collateral ligaments and all portions of the accessory collateral ligaments during flexion. *p < 0.05.

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The mean length of the dorsal portion of the radial accessory collateral ligament decreased by only 0.6 mm (from 14.0 ± 2.6 to 13.4 ± 2.6 mm, p < 0.05) during flexion, and the mean length of the middle portion decreased by only 1.3 mm (from 12.3 ± 2.9 to 11.0 ± 2.5 mm, p < 0.05). Likewise, the mean length of the dorsal portion of the ulnar accessory collateral ligament changed little (from 12.7 ± 1.3 to 12.7 ± 1.6 mm, p = 0.43) during flexion, and the mean length of the middle portion changed by only 0.8 mm (from 11.8 ± 1.2 to 11.0 ± 1.5 mm, p < 0.05). The mean length of the volar portion of the radial accessory collateral ligament decreased by 2.4 mm (from 11.6 ± 3.2 to 9.2 ± 2.2 mm, p < 0.05) during flexion, and the mean length of the volar portion of the ulnar accessory collateral ligament decreased by 1.9 mm (from 11.3 ± 1.5 to 9.4 ± 1.4 mm, p < 0.05) ( Fig. 6, C and D). Despite the difference in paths, there was no significant difference in the change in length of either the radial or the ulnar accessory collateral ligament among the fingers (see Appendix).

Change in the Osseous Contact Region and in the Width of the Contact Region During Flexion

The contact region between the articular surfaces at 0°, 20°, 40°, 60°, and 80° of flexion is shown in Figure 7. The contact region changed from the narrow, distalmost region of the metacarpal to the wider, volar region of the metacarpal head during flexion. The width of the contact region on the metacarpal head increased from 7.1 ± 2.1 to 10.0 ± 1.0 mm (p < 0.05) during flexion.

Fig. 7

Three-dimensional models of the metacarpal (top, viewed from the distal side) and the proximal phalanx (bottom, viewed from the distal-volar-ulnar side) in 0°, 20°, 40°, 60°, and 80° of flexion of the metacarpophalangeal joint. The inferred region of contact between the bones (where their proximity is ≤1.5 mm) is shown in green.

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Discussion

Although the collateral ligaments have been described as major stabilizers of the metacarpophalangeal joint¹, we questioned their ability to prevent volar subluxation of the proximal phalanx in extension, as the collateral ligaments are tight in flexion but lax in extension^1,2,15. Some investigators^3,16 have suggested that the accessory collateral ligaments would prevent volar subluxation, but the function of the accessory collateral ligaments has not been clearly determined. One reason for this lack of knowledge may be the absence of quantitative measurements of the change in length of the accessory collateral ligaments during flexion. We found that the accessory collateral ligaments curved around the volar tubercle of the metacarpal head at all flexion angles, which would have hindered accurate measurement of the change in length with use of the direct distance between the attachment sites on biplanar radiographs⁵. We used a recently developed technique¹² in the current study that enabled us to investigate the change in length of a curved ligament more accurately than with use of a biplanar radiographic technique.

We noted that the volar portion of each collateral ligament and the dorsal and middle portions of each accessory collateral ligament behaved in a nearly isometric manner during flexion. These isometric fibers originated dorsal to the center of curvature of the surface of the metacarpal head, unlike the situation in the proximal interphalangeal joint, in which the collateral ligament originates at the center of rotation¹⁷ and inserted almost on the volar plate. Although the dorsal and middle portions of each accessory collateral ligament have been thought to be less important than the collateral ligaments, we suggest that they may be the most important ligamentous structures preventing volar subluxation of the metacarpophalangeal joint.

Although the volar portion of each collateral ligament is taut in extension, it does not hinder abduction-adduction movement at this orientation because it originates from the apex of the lateral tubercle and space exists between it and the metacarpal head in extension. The dorsal and middle portions of each accessory collateral ligament are also taut in extension but do not hinder some abduction-adduction movement, probably because of the existence of some mobility of the volar plate in which these fibers insert. Therefore, we speculate that these isometric fibers allow some motion in the abduction-adduction plane in extension while remaining taut.

The width of the contact region between the metacarpal head and the proximal phalange changes considerably during flexion because of the unique shape of this region of the metacarpal head. We found that the contact region changed from the distalmost, narrow region of the metacarpal head to the volar, wider region of the metacarpal head during flexion. The center portion of the metacarpal head is spherical, whereas the volar portion is bicondylar¹⁷. We suggest that the broad region of osseous contact in flexion contributes to the stability of the metacarpophalangeal joint and that the narrow region of osseous contact in extension makes this joint hypermobile in the abduction-adduction plane. The shape of the center portion of the metacarpal head differed among the digits.

The current study has several limitations. First, the embalming process probably had some effect on the mechanical properties of the ligaments^18,19. Second, the small number of specimens limits the accuracy of the comparisons. Third, the accuracy of the proximity mapping method is limited by the lack of physiological muscle contraction. Finally, we could not take cartilage thickness into account with or technique.

The results of the current study suggest that each of the collateral and accessory collateral ligaments of the metacarpophalangeal joint can be functionally divided into three portions and that these portions act differently during flexion than during extension. Although the potential contribution of each of the functional portions to the stability of the metacarpophalangeal joint was not tested, our results provide a good starting point for future studies of the contribution that the functional divisions of the collateral and accessory collateral ligaments make to the stability of the metacarpophalangeal joint. For instance, the changes that are produced in the stress-strain curve by serially sectioning various portions of the collateral and accessory collateral ligaments may shed light on pathoanatomy such as the volar subluxation and ulnar drift of the metacarpophalangeal joint that is common in rheumatoid arthritis.

Appendix

Tables showing the mean lengths of the ligament portions in each finger and a figure showing changes in the arc heights of the accessory collateral ligaments during flexion are available with the online version of this article at jbjs.org.

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Topics

collateral ligaments ; ligaments ; metacarpophalangeal joint ; fingers ; metacarpal bone ; ulnar collateral ligament ; flexion ; metacarpal head

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Toshiyuki Kataoka, Hisao Moritomo, Junichi Miyake, Tsuyoshi Murase, Hideki Yoshikawa, Kazuomi Sugamoto; Changes in Shape and Length of the Collateral and Accessory Collateral Ligaments of the Metacarpophalangeal Joint During Flexion. The Journal of Bone & Joint Surgery. 2011 Jul;93(14):1318-1325.

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