How to treat a volar (palmar surface) fracture of the fifth digit proximal interphalangeal (PIP) joint?

Treatment of Volar Fracture on Fifth Digit PIP Joint

Buddy taping with early active motion is the recommended treatment for volar fractures of the fifth digit proximal interphalangeal (PIP) joint that are stable and without subluxation. 1, 2

Assessment and Classification

• Evaluate fracture stability with radiographic evaluation including at least three projections (posteroanterior, lateral, and oblique) to properly characterize the fracture 3
• Determine if the fracture involves a volar avulsion component and whether there is any joint subluxation or dislocation 4
• Assess the integrity of the extensor mechanism, as volar fractures may disrupt the central slip attachment 4

Treatment Algorithm

For Stable Volar Fractures (without subluxation)

• First-line treatment: Buddy taping with adjacent digit 1, 2

  • Provides stability while allowing early active motion
  • Results in excellent outcomes in up to 66% of patients 1
  • Minimizes joint stiffness compared to rigid immobilization 1
  • Allows for faster recovery and easier patient compliance 1

• Alternative: Extension block splinting in 10° flexion 1

  • Can be used if buddy taping is insufficient for stability
  • Custom-made to prevent hyperextension while allowing flexion
  • Similar outcomes to buddy taping but more restrictive 1

• Adjunctive treatment: Dorsal night splinting in 10° flexion 1

  • Recommended for both buddy taping and extension block splinting approaches 1
  • Helps maintain proper alignment during healing

For Unstable Volar Fractures (with subluxation or dislocation)

• Surgical intervention is indicated 5, 6
  • Options include:
    • Volar plate arthroplasty using suture anchors 6
    • Open reduction internal fixation with transverse volar plating ("Seatbelt procedure") for fractures involving >40% of articular surface 5

Rehabilitation Protocol

• Early active motion is critical to prevent stiffness 7, 1

  • Begin active finger motion exercises immediately following diagnosis and treatment 7
  • Active motion helps prevent the most functionally disabling adverse effect: hand stiffness 7

• Duration of treatment

  • Typically 6-9 weeks for buddy taping 1
  • Similar duration for extension block splinting 1
  • Regular follow-up to assess healing and range of motion 1

Expected Outcomes

• With appropriate treatment, 95-96% of stable volar PIP fractures achieve good to excellent results 1, 2
• Expected range of motion after treatment:
  • For surgical cases: average PIP arc of motion of approximately 77-82° 5, 6
  • For non-surgical cases: median total active motion of 90-95° 1

Potential Complications

• Joint stiffness - most common complication, minimized by early active motion 7
• Boutonnière deformity - can occur if the extensor mechanism is disrupted and not properly treated 4
• Chronic pain or instability - may require surgical intervention if conservative measures fail 6

Follow-up Recommendations

• Regular radiographic evaluation for the first 3 weeks and at cessation of immobilization 7
• Monitor for any signs of subluxation, loss of reduction, or development of boutonnière deformity 4
• Assess range of motion progress at each follow-up visit 1