What is the treatment for a volar plate avulsion fracture?

Treatment of Volar Plate Avulsion Fractures

For stable volar plate avulsion fractures without joint subluxation, initiate immediate active finger motion exercises with buddy taping to an adjacent digit, avoiding rigid immobilization that leads to stiffness—the most functionally disabling complication of these injuries.

Initial Assessment

Obtain radiographic evaluation with at least three projections to characterize the fracture and assess stability 1. The critical determination is whether the joint remains stable and whether the bony fragment involves less than 30% of the intra-articular surface 2.

Treatment Algorithm Based on Fracture Characteristics

Stable Fractures (No Subluxation, Fragment <30%)

Conservative management with early mobilization is the treatment of choice:

• Immediate active finger motion exercises should begin at diagnosis to prevent joint stiffness 3, 4
• Buddy taping to the adjacent digit provides stability while allowing early active motion 1
• Extension-stop splinting for approximately 2 weeks (mean 16 days), limiting dorsiflexion to protect the healing volar plate 3, 2
• Dorsal night splinting in 10° flexion helps maintain alignment during the initial healing phase 1
• Coban bandage during the day until 6 weeks post-injury for edema control 2

This approach achieves excellent or good outcomes in 98% of cases 4. Importantly, the size and displacement of the avulsed fragment do not affect outcomes when the joint remains stable 4.

Weight-Bearing Restrictions

Avoid weight bearing for approximately 2 weeks, then initiate protected weight bearing with a splint limiting dorsiflexion 3.

Unstable Fractures or Large Fragments

Surgical intervention is indicated when:

• Joint instability is present on examination 2
• Fragment involves ≥30% of the intra-articular surface 2
• Persistent subluxation despite conservative measures 2

Surgical options include:

• Percutaneous K-wire fixation for displaced and rotated large fragments, achieving mean active motion of -1.3°/86.2° at the PIP joint with 94.6% total active motion 5
• Bone anchor fixation (Mitek) or PDS bone suturing for volar plate reattachment, followed by 2 weeks of dorsal protective splint immobilization 6
• FDS tenodesis for unstable volar plate in hyperextension 2

Monitoring and Follow-Up

• Radiographic evaluation during the first 3 weeks and at cessation of immobilization 1
• Clinical assessment every 2 weeks for the first 3 months using high-resolution ultrasound to evaluate volar plate stability and soft tissue edema resolution 2
• Further imaging only if clinically indicated (new trauma, significant pain, loss of range of motion, or neurovascular symptoms) 3

Common Pitfalls and Management

Flexion contracture is the most common complication 1, 2:

• Occurs in approximately 23% of cases (18/78 patients in one series) 2
• Prevented by immediate full extension splinting at night and Coban bandage during the day 2
• If contracture develops (>10°), initiate dynamic extension splints for 3-5 months 2

Delayed presentation (>3 weeks from injury) results in worse outcomes 4. These patients may require more aggressive rehabilitation or surgical intervention 7.

Concomitant collateral ligament rupture results in greater extension lag but overall successful outcomes with surgical volar plate reattachment 6.