What is the treatment for a volar plate avulsion fracture?

Treatment of Volar Plate Avulsion Fractures

Conservative management with early active mobilization is the recommended treatment for volar plate avulsion fractures with less than 50% joint involvement, stable joint, and minimal displacement (less than 10 degrees angulation). 1

Assessment and Diagnosis

1. Initial Imaging:

   • Standard radiographs (3 views: posteroanterior, lateral, and oblique) for initial diagnosis 1
   • CT without contrast if radiographs are equivocal but clinical suspicion remains high 1
   • MRI without contrast can evaluate associated soft tissue injuries, particularly volar plate tears 1

2. Key Assessment Parameters:

   • Percentage of joint surface involvement
   • Joint stability
   • Degree of displacement/angulation
   • Fragment rotation
   • Associated injuries (collateral ligament tears)

Treatment Algorithm

Conservative Management (First-line for most cases)

Indicated for:

• Fractures with <50% joint involvement
• Stable joint
• Minimal displacement (<10 degrees angulation) 1

Treatment protocol:

• Early active mobilization with minimal or no splintage 2
• Extension stop splinting for approximately 2 weeks followed by Coban bandage until 6 weeks post-injury 3
• NSAIDs for pain and inflammation control 1
• Directed home exercise program including active motion exercises 1

Surgical Management

Indicated for:

• Fractures involving >50% of articular surface
• Unstable joints
• Displacement with interfragmentary gap >3mm
• Significant angulation (>10 degrees)
• Malrotation 1

Surgical options:

• Open reduction and internal fixation (ORIF) 1
• Volar plate reattachment using Mitek bone anchoring or PDS bone suturing 4
• Fragment excision for smaller fragments 5

Key Considerations and Pitfalls

1. Timing Matters: Patients presenting more than three weeks from injury tend to have worse outcomes 2. Early intervention is crucial.

2. Fragment Size Assessment: The true size of fracture fragments is often larger than expected based on X-ray, and fragments are usually rotated by pull of the volar plate or ligament 5. This may influence treatment decisions.

3. Associated Injuries: Concomitant collateral ligament rupture can lead to greater extension lag despite successful volar plate reattachment 4. Careful assessment for associated injuries is essential.

4. Monitoring and Follow-up:

   • Regular assessment of healing and joint function
   • High-resolution ultrasound can evaluate palmar plate stability and guide safe return to full range of movement 3
   • Consider dynamic extension splints for patients developing flexion contracture 3

5. Potential Complications:

   • Joint stiffness
   • Chronic pain
   • Recurrent instability
   • Post-traumatic arthritis
   • Extensor lag 1

6. Special Consideration: Combined central slip and volar plate avulsion injuries may require full extension splinting 6.

The evidence strongly supports early active mobilization for most volar plate avulsion fractures, with excellent outcomes reported in 98% of cases using this approach 2. Surgery should be reserved for specific indications as outlined above.