What is the treatment for a possible avulsion fracture of the volar aspect of the 5th proximal interphalangeal joint?

Treatment of Avulsion Fracture of the Volar Aspect of the 5th Proximal Interphalangeal Joint

For a possible avulsion fracture of the volar aspect of the 5th proximal interphalangeal joint, the recommended treatment is immobilization in extension (0 degrees) for 7-10 days, followed by buddy taping and active range of motion exercises for up to 3 weeks after injury. 1

Initial Assessment and Imaging

• Radiography with at least 3 views (posteroanterior, lateral, and oblique) is the initial imaging modality of choice for suspected fractures of the hand 2
• CT may be considered if initial radiographs are equivocal but there is high clinical suspicion for fracture 2
• MRI can be useful for evaluating associated soft tissue injuries, particularly for assessing the integrity of the volar plate and collateral ligaments 2

Treatment Algorithm

For Stable Volar Plate Avulsion Fractures:

1. Initial Immobilization:

   • Immobilize the joint in extension (0 degrees) for 7-10 days 1
   • This approach differs from traditional flexion immobilization, which can lead to proximal interphalangeal flexion contractures 1

2. Intermediate Phase:

   • After initial immobilization, transition to buddy taping with active range of motion exercises until 3 weeks post-injury 1
   • Protective buddy taping should be continued until 6 weeks post-injury 1

3. Follow-up:

   • Monitor for development of complications such as joint instability, pain with activity, or limited range of motion 1, 3
   • Long-term follow-up should be adapted to the patient's individual needs based on symptoms and recovery progress 2

For Unstable Fracture-Dislocations:

• Surgical intervention should be considered when there is joint instability, significant displacement, or when conservative treatment fails to provide adequate pain relief and functional recovery 2, 4

• Surgical options include:

  • Percutaneous fixation (which has shown the highest post-operative range of motion in studies) 4
  • Extension-block pinning (which has demonstrated good grip strength outcomes) 4
  • Open reduction and internal fixation for more complex fractures 4, 5

Expected Outcomes

• With proper extension splinting protocol for stable volar plate avulsion injuries, studies show a high percentage of good to excellent results 1
• Patients typically achieve good range of motion without developing hyperextension laxity or flexion contractures 1
• For surgically treated fracture-dislocations, average post-operative range of motion ranges from 79.3° to 86.5° depending on the technique used 4

Potential Complications and Management

• Flexion contracture: This is less common with extension splinting (compared to traditional flexion immobilization) 1
• Hyperextension laxity: Proper immobilization in extension rather than hyperextension helps prevent this complication 1
• Chronic pain and limitation of movement: In cases where conservative treatment fails, surgical repair of the volar plate may be considered 3

Rehabilitation

• Active range of motion exercises should begin after the initial immobilization period (7-10 days) 1
• Buddy taping provides protection while allowing controlled movement during the rehabilitation phase 1
• Hand therapy may be beneficial for patients with persistent stiffness or pain 4, 5

This treatment approach has been shown to provide good outcomes while minimizing the risk of flexion contractures that can occur with traditional flexion immobilization techniques 1.