ADVANCES IN HAND ANATOMY
00
A NEW METHOD OF DIAGNOSING
METACARPOPHALANGEAL
INSTABILITIES OF THE THUMB
Jose Maria Rotella, MD, and Jose Urpi, MD
The increasing popularity and speed of
contact sports and of sports using the thumb
in opposition (motocross, rugby, mountain
bike) have resulted in an increase in the inci-
dence of metacarpophalangeal (MCP) insta-
bilities of the thumb and the subsequent need
for an easy and reliable initial diagnostic
method.
When the MCP joint of the thumb is in-
jured, an accurate assessment of the lesion
is critical. It is essential to determine which
ligament is injured and whether it is totally
or partially torn. Several methods for evaluat-
ing the extent of the injury have been de-
scribed in the literature. The traditional diag-
nosis is based on documentation of joint
instability, assessed using standardized tests
and stress radiographs.vw None of these
methods is absolutely certain or universally
available.
The issue of instability of the MCP joint of
the thumb has become controversial. Many
and varied methods have been described for
diagnosing these types of injuries: Compara-
tive contralateral joint stress; palpation of the
injury': ultrasonography-v 45, 42, 29, 35; NMR4?;
arthroscopy'": arthrography- 1?; stress radio-
graphs": and valgus stress."
From the Deparhnent of Orthopedics, National University of Tucuman, School of Medicine, Tucuman, Argentina
HAND CLINICS
VOLUME 17· NUMBER 1 • FEBRUARY 2001
0749-0712/01 $15.00 + .
ANATOMY
Various authors have studied the anatomy
and physiology of the MCP joint of the thumb
in meticulous detail and these studies are the
foundation for the interpretation of the pa-
thology affecting this joint. 60, 12, 33,69,32, 46 The
MCP joint of the thumb is a condylar joint
with two planes of motion-flexion-exten-
sion and lateral. Some authors acknowledge
reduced planes of axial rotation. This joint
consists of two closely related systems that
provide stability.
Capsular-Ligamentous Apparatus
(Passive Stabilizer)
Volar Aspect (Fig. 1)
The distal two thirds of the joint consists of
a thick structure, the fibrocartilage, glenoid,
or volar plate, that is firmly attached to the
base of the phalanx.
Included in this structure are the two sesa-
moid bones and their intersesamoid ligament.
The proximal third of the joint contains the
weakest membranous head, which is attached
to the metacarpal neck.
45
46 ROTELLA & URPI

the joint is flexed, the MCP ligament begins to

be tensed and the SM ligament is slackened."
Because of the way in which the MCP liga-
ment is attached to the metacarpal head, its
fibers have different isometry. During flexion,
the alar fibers are tensed first, followed by
the volar fibers.
The maximum tightness of the MCP liga-
ment is from 10° of flexion onward. This liga-
ment stabilizes lateral movements and sup-
ports the base of the phalanx from the back
of the metacarpal head, thereby preventing
the volar subluxation of the phalanx (Fig. 2B).

Figure 1. Anatomic dissection. Dorsal view of the volar
plate, showing the sesamoid bones (S), the metacarpal
head (M), and the base of the phalanx (P).
Dorsal Aspect
The dorsal capsule is thin and slack, per-
mitting flexion. The extensor pollicis brevis
tendon reinforces the capsule, is bound to it,
and is attached to the proximal phalanx of
the thumb (Table 1).
MUSCULAR APPARATUS (ACTIVE
STABILIZER)

Lateral Aspect (Fig. 2)

On both sides of the joint there is a liga-
ment sheath that provides stability (Lig. a, b,
c, d). These ligaments are traditionally re-
ferred to as follows (Fig. 3):
(a) metacarpophalangeal ligament
(b) sesamoid-metacarpal ligament
(c) sesamoid-phalangeal ligament
(d) glenoid-phalangeal ligament
Each of these ligaments is perfectly syn-
chronized to stabilize the joint at the different
stages of MCP flexion and extension.
During extension, the SM ligament is
tensed and the MCP ligament is slack. When
This system consists of the intrinsic muscles
(lateral and medial thenar) and the extrinsic
tendons of the thumb (Table 2). The system
provides active stability to the MCP joint in
all thumb positions (Fig. 4B).
Nucleus of the Metacarpophalangeal
Coupling
The sesamoid bones are two structures stra-
tegically located on the volar aspect of the
MCP joint that link the active and passive
stabilizing systems (Fig. SA-B).
The SM and sesamoid-phalangeal liga-
ments balance the traction of the intrinsic

Table 1. CAPSULAR-LIGAMENTOUS APPARATUS

Volar
--------------= Sesamoid bones-intersesamoid lig.
Membranous head

Metacarpophalangeallig.
Capsular-Ligamentous

~
Apparatus < E - - - - - - Lateral Sesamoid-metacarpallig.
(PASSIVE STABILIZER)
Sesamoid-phalangeal lig.
Glenoid-phalangeal lig.

Dorsal - - - - - Extensor pollicis brevis tendon

 A NEW METHOD OF DIAGNOSING Mep INSTABILITIES OF THE THUMB 47

Figure 2. A and B, Anatomic dissections. Lateral (ulnar) view of the

metacarpophalangeal joint: metacarpal (M); phalanx (P); metacarpo-
phalangeal ligament (MP); sesamoid-metacarpal ligament (8M); ses-
amoid-phalangeal ligament (8P).

muscles reaching this point; the sesamoid

Figure 3. The normal position of the lateral ligament
of the metacarpophalangeal joint of the thumb. MP =
metacarpophalangeal ligament; 8M = sesamoid-meta-
carpal ligament; GP = glenoid-phalangeal ligament; 8P
= sesamoid-phalangeal ligament.
bones are therefore the convergence point of
the periarticular structures and form a true
"nucleus of force coupling" for the MCP joint
of the thumb."
When this joint is affected by trauma, this
perfect balance of forces is lost and different
instabilities occur. Mechanoreceptors provide
the internal information needed for this sys-
tem to function. Mechanoreceptors in the liga-
ments and receptors in the tendinous spindles
of the intrinsic muscles are stimulated to ef-
fect mechanical traction, thereby producing
the immediate muscle guard response of the
MCP joint.
An understanding of the relevance of this
anatomic structure and its role in maintaining
joint stability is essential to understanding
the pathology and implementing an effective
treatment.
48 ROTELLA & URPI

Table 2. INTRINSIC MUSCLES AND EXTRINSIC TENDONS OF THE THUMB: THE MUSCULAR APPARATUS

______ Phalanx
Oblique,",,-------
Medial - - - Adductor pollicis ~ Extensor apparatus

<
Transverse IMedial sesamoid bone I

<
INTRINSIC
Phalanx
Superficialis
Flexor pollicis brevis Extensor apparatus

Lateral ~ Profundus ~I I>lem1 ~oirl boo, I

\ Phalanx
Abductor pollicis brevis Extensor apparatus

Extensor pollicis brevis tendon

EXTRINSIC Extensor pollicis longus tendon

Flexor pollicis longus tendon

 A NEW METHOD OF DIAGNOSING Mer INSTABILITIES OF THE THUMB 49

Figure 4. Intrinsic muscles. A, Anatomic dissection of the attachments of the

adductor pollicis brevis: 1 = attachment to the phalanx and medial (ulnar)
sesamoid bone; 2 = aponeurotic expansion for the extensor; M = metacar-
pal; P = phalanx. B, Attachments of the flexor pollicis brevis (FPB) and the
abductor pollicis brevis (APB). 8 = sesamoid bones; AE = alar aponeurotic
expansion; MP = metacarpophalangeal ligament; GP = glenoid-phalangeal
ligament; 8P = sesamoid-phalangeal ligament; 8M = sesamoid-metacarpal
ligament.
50 ROTELLA & URPI

B
Figure 5. Volar plate. A, Anatomic dissection of the volar aspect of the metacarpophalangeal joint,
showing the attachments of intrinsic muscles and the convergence of forces on the sesamoid bones
(8). M = metacarpal; P = phalanx. B, Nucleus of coupling. A cross-section of the metacarpopha-
langeal joint. M = metacarpal; P = phalanx; AE = alar aponeurotic expansion; 8 = sesamoid
bones; 18 = intersesamoid ligament (I); FT = flexor tendon; MP = metacarpophalangeal ligament;
8M = sesamoid-metacarpal ligament; APB = abductor pollicis brevis (APB); APB = flexor pollicis
brevis with its superficialis and profundus bundles; TE = extensor tendon.

MATERIALS AND METHODS
This article describes the materials and
methodology used to achieve a complemen-
tary diagnostic method for use in cases of
instability of the MCP joint of the thumb.
The purpose of the study was clinical, ana-
tomic, and biomechanical. Several clinical-
radiologic studies were carried out on pa-
tients and dissections were performed on
fresh anatomic specimens.
Radiologic Study
To determine the behavior of the sesamoid
bones at different degrees of flexion and ex-
tension of the MCP joint of the thumb and
to standardize their normal and pathologic
displacement for precise diagnosis in cases of
instability of the MCP joint, the authors stud-
ied radiographs to assess the displacement of
the sesamoid bones in a series of 20 patients
without joint pathology and in a series of 17
patients with affected joints.
Anteroposterior radiographs were taken
with the hand and forearm fully prone and
the alar aspect of the thumb and the first
metacarpal lying on the radiographic plate.
The beam was focused on the metacarpal
head. In this position, stress maneuvers were
used to assess each ligament.
The sesamoid bones play a key role in the
stability of this joint because they are the true
nucleus of force coupling as a result of their
strategic location between the capsular-
ligamentous and muscular systems. When-
ever sesamoid bones are examined on radio-
graphs, the ligament structures normally
attached to them must also be considered
(Fig.6B).
Any abnormal displacement of the sesa-
moid bones, in either the longitudinal or lat-
eral planes, entails a rupture of their normal
stabilizing ligaments. This can be shown and
documented with a plain anteroposterior
stress radiograph of the MCP joint of the
thumb and by assessing whether or not the
intersesamoid axis is parallel to the metacar-
pal head and phalangeal base.
The following are the conclusions from the
radiographic study with stress on the MCP
 A NEW METHOD OF DIAGNOSING Mep INSTABILITIES OF THE THUMB 51

Figure 6. A, Lateral radiograph of normal MP joint of the thumb. B, Assess ligament position on a
lateral radiograph of the metacarpophalangeal joint. MP = metacarpophalangeal ligament; 8M =
sesamoid-metacarpal ligament; 8P = sesamoid-phalangeal ligament; GP = glenoid-phalangealllga-
ment.

joint of the thumb performed in 20 patients
without ligament lesions.
• With the joint extended, there was no dis-
placement and the axis of the sesamoid
bones remained parallel to the metacar-
pal head.
• With the joint flexed, there was a loss of
parallelism between the sesamoid axis
and the phalanx, no greater than 5° to
10°, depending on the slackness of each
patient's joint. At no point in the
flexion-extension of the joint was paral-
lelism between the sesamoid axis and the
metacarpal head lost.
The following are the conclusions from the
radiographic study with stress on the MCP
of the thumb performed in 17 patients with
ligament lesion:
• Six patients (35.3%) showed a loss of par-
allelism between the sesamoid bones and
the metacarpal; they were evaluated with
their joint extended, implying injury to
the MCP and SM ligaments. The sesa-
moid bones were displaced together with
the phalanx, indicating that the glenoid
fibrocartilage had been spared (Fig. 7A) .
• Eleven patients (64.7%) showed a loss of
parallelism between the sesamoid bones
and the phalanx; they were evaluated
with their joint bent 15°, implying injury

Figure 7. A, A serious ligament lesion, entailing loss of parallelism between the metacar-
pal and the sesamoid bones. B, A mild lesion with no loss of metacarpal-sesamoid
parallelism.
52 ROTELLA & URPI

to the MCP ligament. The joint was stable
in extension (the SM ligament was intact)
and the sesamoid bones remained parallel
to the metacarpal (Fig. 7B).
Anatomic Study
A study was carried out on fresh anatomic
specimens and each maneuver was docu-
mented iconographically, radiographically,
and goniometrically.
The anatomic material was divided into
two groups. One group (five specimens) was
studied to assess:
The Role Played by Each of the
Anatomic Elements in Stabilizing
the Metacarpophalangeal Joint
of the Thumb.
A careful anatomic dissection was carried
out of each ligament and stress maneuvers
were performed at different stages of the
flexion-extension of the MCP joint of the
thumb. The following conclusion were
reached:
• The capsular-ligamentous apparatus is
responsible for the passive stability of the
joint, with no involvement of the periar-
ticular aponeurotic system."
• With the joint flexed 15°, the main lateral
passive stabilizer is the MCP ligament (a)
given that, in this position, its points of
attachment are drawn away from each
other. 50 The SM ligament is slack (b) (Fig.
8A).
• With the joint EXTENDED, the main lat-
eral passive stabilizer is the SM ligament
(b) (Fig. 8B).
The MCP ligament slackens because its
points of attachment are drawn closer to-
gether.

Figure 8. Anatomic dissections showing the function of the metacar-

pophalangeal ligaments when flexed (A) and when extended (B). The
metacarpophalangeal ligament and the sesamoid-metacarpal liga-
ment unfurl because of their isometric attachment to the metacarpal
head. M = metacarpal; P = phalanx.
 A NEW METHOD OF DIAGNOSING Mep INSTABILITIES OF THE THUMB
Each Ligament was Sectioned at
Selected Points and the Resulting
Displacements Documented
The following conclusions were reached:
• When the MCP ligament was sectioned
and a stress maneuver performed with
the joint extended 0°, the result was a
joint opening of less than 30°; the sesa-
moid bones were not displaced from their
normal position with respect to the meta-
carpal (Fig. 9A, B).
• When the MCP and SM ligaments were
sectioned, the result was total lateral in-
stability and a joint opening of more than
45°; the sesamoid bones were displaced
together with the phalanx and lost their
normal parallelism with respect to the
metacarpal (Fig. IDA, B).
Reproduction of Injury Mechanisms
The second group (eight specimens) con-
sisted of entire fresh cadaver hands with no
previous anatomic dissection. This batch was
used to study the different mechanisms likely
to cause instability of the MCP joint of the
thumb. The valgus stress maneuver was per-
formed with the joint flexed in four of the
specimens and the joint extended in the other
four. Following the maneuver, the anatomic
dissection was performed and the resulting
ligament lesions ascertained. The following
conclusions were reached:
Figure 9. A, Anatomic specimen in which the metacarpophalangeal ligament was sectioned at its
distal attachment to the phalanx. B, The same specimen: parallelism between the metacarpal and
the sesamoid bones is maintained.
53
With lateral stress and the joint flexed.
Total rupture of the MCP ligament occurred
at its distal point of attachment; goniomet-
rically, there was a lateral opening of less than
30°. The joint remained stable in extension
because the SM ligament was intact. The sesa-
moid bones remained parallel to the metacar-
pal (Fig. llA-e). If the injury mechanism con-
tinued, rupture of the SM ligament followed;
only then was parallelism between the sesa-
moid bones and the metacarpal lost and only
then did the aponeurosis of the extensor snag
the MCP ligament.
With lateral stress and the joint extended.
In the first stage, the SM ligament tore (b),
resulting in the joint opening more than 30°.
If stress continued, a second stage took place
almost immediately; the MCP ligament tore
at its proximal attachment (metacarpal) (a).
Goniometrically, the joint opening was more
than 45°. The sesamoid bones lost their paral-
lelism with the metacarpal and were dis-
placed with the phalanx (Fig. 12A-e).
In none of the cases, when the joint was
subjected to maximum stress, did distal de-
tachment of the glenoid fibrocartilage occur,
because it is firmly attached to the base of the
phalanx. In all cases, its proximal membra-
nous head (attachment to the metacarpal
neck) was torn.
Of all the mechanisms studied, the one
causing the most serious ligament injuries
and therefore the greatest instability of the
joint was the lateral movement with the MCP
54 ROTELLA & URPI

Figure 10. A, Anatomic specimen with metacarpophalangeal

and sesamoid-metacarpal ligaments sectioned at the metacarpal
neck. B, The same specimen showing the loss of parallelism
between the metacarpal and the sesamoid bones.
 A NEW MElHOD OF DIAGNOSING Mep INSTABILITIES OF THE lHUMB 55

Figure 11. A, Anatomical dissection of the specimen previously subjected to a forced hyperab-
duction maneuver with the metacarpophalangeal joint flexed, resulting in distal rupture of the
metacarpophalangeal ligament. B, Radiograph of the same specimen showing that parallelism
between the metacarpal and the sesamoid bones is maintained. C, Rupture of the metacarpo-
phalangeal bundle. MP = metacarpophalangeal ligament; 8M = sesamoid-metacarpal liga-
ment; 8 = sesamoid ; M = metacarpal; P = phalanx.
56 ROTELLA & URPI

Figure 12. A. Anatomical dissection of a specimen subjected to a forced hyperabduction maneuver

with the MP joint extended, resulting in proximal avulsion at the metacarpal neck. B, The same
specimen showing loss of parallelism between the metacarpal and the sesamoid bones 8
sesamoid bones; P = phalanx; M = metacarpal. C. The rupture seen during dissection. 8M
sesamoid-metacarpal ligament; MP = metacarpophalangeal ligament.

joint extended. Stener's lesion (interposition
of the adductor pollicis tendon) occurs when
the angular opening or displacement of the
phalanx exceeds 35° to 40°.
If a rotational factor is added to any of
these mechanisms, the lesion is increased at
the site at which the rotation takes place (Fig.
13A, B)
DISCUSSION
The therapeutic approach in these cases is
a matter of controversy in the literature. Some
authors prefer to use immobilization in a
plaster cast to treat all acute lesions and refer
to surgery only for joints with residual insta-
bility.": 34, 44, 54 Most authors, however, advo-
cate early repair as the optimal method for
achieving maximal recovery." 11, 13, 22, 48. 67
If the patient shows generalized joint slack-
ness and there is uncertainty regarding the
existence of injury, the stress maneuver can
be performed on the opposite thumb to deter-
mine whether displacement of the sesamoid
bones exists. In none of the cases assessed in
the authors' study was parallelism with the
metacarpal lost. The sesamoid bones therefore
are a reliable parameter for diagnosing the
location of the injury and are closely related
to the surgical pathology of ligament rupture,
as shown by the anatomic dissections and
radiologic studies carried out.
The authors advocate acute ligament repair.
 A NEW METHOD OF DIAGNOSING Mel' INSTABILITIES OF THE THUMB 57

c
Figure 13. A, Anatomical dissection showing the tendency of the phalanx to rotate on the metacarpal
bone after losing ligament support on that side. B, The deformities generated by the alteration of the
forces described . C, Chronic instability showing the rotation of the phalanx on the metacarpal bone.

This procedure provides the best functional
results because it is possible to join the ends
of the tom ligaments easily. Ligament recon-
struction is critical for restoring the capsular-
ligamentous mechanoreceptor apparatus pro-
tecting the joint against abnormal forces and
use. In general, remnants of ligament tissue
remain attached to the bone. This permits an
end-to-end repair. When there are no rem-
nants of ligament, bone anchors are used.
Following repair, the joint is protected for
2 weeks and then treatment to restore joint
mobility is started.
Early surgical repair is emphasized primar-
ily in cases of lesions with loss of parallelism
between the sesamoid bones and the metacar-
pal. This is because these lesions have the
worst prognosis and cause the most serious
chronic instabilities. Statistics show a high
percentage (30%) of poor results and residual
joint instability when noninvasive treatment
with plaster cast is used routinely.l" 12,41,57, 60
Statistics also indicate that results following
reconstructive surgery in cases of chronic in-
stability are less than excellent.w 54. 68
The authors believe that ligament lesions
are not all the same because of their location
and their extent. It follows that not all lesions
can be treated in the same way.
Patterns
To determine the type of lesion and its seri-
ousness, an easy, reliable and reproducible
method is needed to locate the injury. The
authors propose that the joint be assessed on
a plain anteroposterior radiograph with stress
on the joint to determine the displacement of
the sesamoid bones and their position with
respect to the metacarpal.
Most acute trauma of the MCP joint of the
thumb causes partial ligament lesions that
can be treated effectivel y by immobilization
for 3 weeks. Some patients require surgery
because the acute ligament lesion is complete.
58 ROTELLA & URPI
Surgery is also necessary in cases in which
noninvasive treatment fails because of mis-
taken initial diagnosis.
The authors' study prompts a new interpre-
tation of the classic Stener's lesion. When
trauma occurs with the joint flexed, distal
detachment of the MCr ligament (from its
phalangeal distal point of attachment) takes
place. This lesion only allows a valgus joint
opening of less than 30°. If trauma continues,
the rupture of the SM ligament follows. This
causes an opening of more than 30°, This
valgus displacement of the phalanx would
allow the aponeurotic sling of the adductor
pollicis to interpose between the joint and the
ligament.
The conclusion is that for Stener's lesion to
occur, the displacement of the phalanx must
be significant. This entails serious injury to
the SM and MCr ligaments, and the resulting
loss of parallelism between the metacarpal
and the sesamoid bones can be observed ra-
diographically.
In cases of· serious chronic instability of
the MCr joint, the patient compensates for
ligament instability by using the active stabi-
lizers (intrinsic thenar muscles). These mus-
cles, however, become tired if made to work
for too long and, consequently, the joint loses
stability again. From the clinical point of
view, they show a pivotal shift of the MCr
joint of the thumb. The authors have divided
chronic instabilities into two types: mechani-
cal instability and physiological instability.
Mechanical Instability
Injury to any of the components of the nu-
cleus of MCr coupling breaks the perfect bal-
ance of forces of this system. Disproportion-
ate traction on one side without the normal
countertraction from the opposite side will
not allow the ligament ends to come together
for normal healing. The imbalance of forces
in joints of low contact and lacking intrinsic
joint stability maintains deformity and in-
creases it with time. If, to this, one adds the
forces involved in the digito-pollicis pinch,
the result is a vicious circle that increases
deformity.
Physiologic Instability
For a joint to function normally, there must
be a close relationship between mechano-
receptors (capsular, ligamentous, thenar-
muscular) that protect the joint at maximum
displacements, sending information for the
muscular system to act in the opposing direc-
tion to that of the force causing the injury.
When a capsular ligament lesion occurs,
mechanoreceptors in these structures lose
their normal position in the nucleus of the
MCr coupling. The intrinsic muscle attached
to the sesamoid bone opposite the injury has
no opposing resistance because of the de-
functionalization of mechanoreceptors in the
tendino-muscular spindles of the intrinsic
muscle attached to the injured side. This leads
to the gradual extension of the lesion, which
occurs as a result of the rupture of the physio-
logic system protecting the joint.
In cases of serious thumb ligament lesion,
passive stabilizers give way and active stabi-
lizers produce abnormal traction. All these
forces are transferred to the base of the pha-
lanx, maintaining deformity, and, if not
treated, this unavoidably leads to chronic in-
stability caused by a number of factors:
1. Greater traction on one side of the base
of the phalanx
2. Off-center traction, resulting in torque
and rotation of the thumb
3. Volar displacement of the phalanx with
respect to the metacarpal head
4. Greater angular displacement of the
phalanx
With time, both capsular and muscular
components retract, hindering normal resto-
ration of the nucleus of coupling. It is this
vicious circle of disproportionate one-sided
traction that prevents unaided stabilization of
the joint and makes surgical repair necessary.
CONCLUSIONS
On the basis of this research, the following
conclusions can be reached:
1. The sesamoid apparatus is the true nu-
cleus of force coupling of the MCr joint
of the thumb and plays a critical role in
joint stability.
2. In a MCr joint with no ligament lesion,
parallelism between the sesamoid axis
and the metacarpal head is at no point
lost during the flexion or extension of
the joint.
3. A plain anteroposterior stress radio-
graph of the joint allows physicians to
determine which ligaments are injured
and the exact location of the injury,
 A NEW METHOD OF DIAGNOSING MCP INSTABILITIES OF THE THUMB
following the patterns of displacement
of the sesamoid bones.
4. When the MCP and SM ligaments are
injured, there is total lateral instability
and a joint opening of more than 45°;
radiographically, parallelism between
the sesamoid bones and the metacarpal
is lost.
5. Of all the mechanisms affecting the MCP
joint of the thumb that were studied,
that causing the most serious lesion and
therefore greatest instability was lateral
movement with the joint extended.
6. The abnormal displacement of the sesamoid
bones shown by radiograph is a reliable
parameter for diagnosing the location of
the injury and is closely related to the
surgical pathology of ligament rupture,
as shown by the anatomic, radiologic,
and clinical studies described.
7. This is a simple and low-cost method
that can be implemented in any emer-
gency department.
References
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59
12. Coonrad RW: A study of the pathological findings
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