What is the treatment for an intra-articular volar plate fracture?

Treatment of Intra-articular Volar Plate Fractures

For intra-articular volar plate fractures, volar locked plating is recommended as the preferred surgical approach due to earlier recovery of function in the short term compared to other fixation methods. 1

Surgical Management Options

The 2022 American Academy of Orthopaedic Surgeons (AAOS) guidelines provide strong evidence regarding the treatment of intra-articular fractures:

• Volar locked plating - Provides earlier functional return (within 3 months) compared to other techniques 1
• Alternative fixation methods include:
  • Dorsal plating
  • External fixation with Kirschner wires
  • Closed reduction with percutaneous fixation

Key Considerations for Surgical Approach

1. Volar approach technique:

   • Exposure through standard flexor carpi radialis approach
   • Careful reduction of intra-articular fragments
   • Application of volar locking plate
   • Precise screw length measurement to prevent tendon irritation 2

2. Arthroscopic assessment:

   • May be considered to evaluate articular reduction quality
   • Studies show fluoroscopic evaluation may underestimate step and gap deformities 3

3. Fixation outcomes:

   • All fixation techniques show similar long-term outcomes at one year
   • Volar locked plating demonstrates superior early functional recovery 1
   • Fracture union typically occurs by 3 months post-injury 4

Post-Operative Management

1. Immobilization:

   • Average immobilization duration: 3-4 weeks
   • Clinical and radiographic reassessment at 2-3 weeks to evaluate healing progression

2. Rehabilitation:

   • Early range of motion exercises after immobilization period
   • Progressive strengthening exercises
   • Full recovery typically expected within 6-8 weeks

3. Pain Management:

   • Multimodal and opioid-sparing protocols when possible 1
   • NSAIDs for pain and inflammation control
   • Ice application during first 3-5 days for symptomatic relief

Special Considerations

1. Elderly patients:

   • Evaluate for osteoporosis risk factors
   • Consider calcium and vitamin D supplementation
   • Orthogeriatric co-management improves functional outcomes

2. Complications to monitor:

   • Loss of reduction (rare with proper fixation)
   • Tendon irritation from hardware
   • Ulnar nerve symptoms

Follow-up Protocol

• Reduced radiographic follow-up may be appropriate (no difference in outcomes with fewer radiographs) 1
• Clinical indications for additional imaging include:
  • New trauma
  • Pain score >6 on VAS scale
  • Loss of range of motion
  • Neurovascular symptoms

Treatment Algorithm

1. Initial evaluation:

   • Assess fracture pattern and stability
   • Evaluate patient's functional demands and comorbidities

2. Decision for operative vs. non-operative:

   • Unstable intra-articular fractures generally require operative fixation
   • Stable non-displaced fractures may be treated non-operatively

3. Operative approach:

   • Volar locked plating for most intra-articular fractures
   • Consider alternative fixation methods based on fracture pattern

4. Post-operative care:

   • Limited immobilization (3-4 weeks)
   • Early range of motion when appropriate
   • Progressive rehabilitation protocol

The AAOS guidelines emphasize that while all fixation techniques show similar long-term outcomes, volar locked plating provides better early functional recovery, which may be particularly important for patients with higher functional demands 1.