What is the treatment for a non-displaced volar plate avulsion fracture?

Treatment of Non-Displaced Volar Plate Avulsion Fracture

The recommended treatment for a non-displaced volar plate avulsion fracture is early active mobilization with minimal or no splinting, as this approach provides excellent outcomes in 98% of cases. 1

Initial Assessment and Management

Diagnosis

• Standard radiographs are recommended as initial imaging to confirm diagnosis and rule out associated fractures
• Ultrasound can be useful for confirming diagnosis and identifying anatomical variations
• CT without IV contrast may be considered in equivocal cases to better visualize fracture morphology

Treatment Algorithm

1. Confirm joint stability:

   • Ensure the joint is stable and the avulsed fragment involves less than 30% of the articular surface
   • If the joint is unstable or fragment is >30%, surgical consultation may be needed

2. Conservative management:

   • For stable, non-displaced fractures, implement early active mobilization
   • Minimal or no splinting is required for most cases
   • If protection is needed, an extension stop splint may be used for approximately 2 weeks 2

Rehabilitation Protocol

Immediate Phase (0-2 weeks)

• Begin active range of motion exercises immediately
• If mild protection is needed, an extension stop splint can be used
• Apply ice for the first 3-5 days to provide symptomatic relief

Intermediate Phase (2-4 weeks)

• Discontinue splinting (if used) after 2 weeks
• Progress to full active range of motion exercises
• Consider Coban bandage for edema control until 6 weeks post-injury 2

Late Phase (4-8 weeks)

• Continue progressive range of motion exercises
• Full recovery is typically expected within 6-8 weeks
• Home exercise program should be implemented to promote optimal recovery

Pain Management

• NSAIDs are recommended for pain and inflammation control
• Oral analgesics can be used for residual pain
• Ice application during the first 3-5 days provides symptomatic relief

Monitoring and Follow-up

• Clinical reassessment at 2-3 weeks to evaluate healing progression
• Ultrasound can be used to evaluate volar plate stability and assess reduction of edema 2
• Monitor for complications such as:
  • Flexion contracture (most common complication)
  • Joint instability
  • Persistent pain

Special Considerations and Pitfalls

Common Pitfalls

• Delayed presentation: Patients presenting more than three weeks from injury tend to have worse outcomes 1
• Over-immobilization: Extended immobilization can lead to stiffness and flexion contracture
• Missed instability: Failure to identify unstable joints requiring surgical intervention

Management of Complications

• For flexion contracture, implement dynamic extension splints
• If instability develops, surgical consultation is warranted
• For persistent pain beyond expected healing time, consider additional imaging to rule out other pathologies

Risk Factors for Poor Outcomes

• Delayed presentation (>3 weeks)
• Concomitant collateral ligament rupture (leads to greater extension lag) 3
• Inadequate rehabilitation

The evidence strongly supports early active mobilization for non-displaced volar plate avulsion fractures, as this approach leads to excellent functional outcomes while avoiding the complications associated with prolonged immobilization.