Treatment of Non-Displaced Volar Plate Fracture at PIP Joint in a 14-Year-Old
For a 14-year-old with a non-displaced volar plate fracture at the base of the second middle phalanx, initiate conservative management with buddy taping to the adjacent finger, dorsal night splinting in 10° of flexion, and immediate active finger motion exercises. 1
Initial Management Approach
Conservative treatment is the appropriate first-line management for stable, non-displaced volar plate avulsion fractures of the PIP joint in pediatric patients. 2, 3
Immobilization Strategy
- Apply buddy taping to the third digit (adjacent finger) to provide stability while permitting early active motion 1
- Use dorsal night splinting with the PIP joint positioned in 10° of flexion to maintain proper alignment during healing 1
- Ensure the splint never obstructs full finger range of motion, as finger stiffness is one of the most functionally disabling complications 4
Critical Early Intervention
- Begin immediate active finger motion exercises upon diagnosis to prevent joint stiffness, which is the most common complication of these injuries 1
- Active finger motion does not adversely affect adequately stabilized fractures and is extremely cost-effective 5, 4
- This early mobilization is particularly important in the 10-14 age group, which has the highest incidence of phalangeal fractures 3
Monitoring and Follow-Up Protocol
Radiographic Surveillance
- Obtain follow-up radiographs at approximately 3 weeks to confirm maintenance of alignment 4
- Repeat imaging at the time of immobilization removal 4
- Use at least three radiographic projections to properly characterize the fracture and assess for any displacement 1
Assessment for Treatment Failure
Watch specifically for these indicators that conservative management may fail:
- Displacement or rotation of the fracture fragment (even if initially small) is the strongest predictor of conservative treatment failure 2
- Joint dislocation at the time of injury increases failure risk 2
- Persistent pain or progressive flexion contracture after initial treatment 2
- Loss of reduction with displacement >3mm requires surgical intervention 4
Common Pitfalls to Avoid
- Do not restrict finger motion - prolonged immobilization increases stiffness risk significantly 5, 4
- Do not rely solely on MRI for diagnosis, as it has demonstrated low sensitivity for volar plate injuries in pediatric patients 6
- Do not assume all non-displaced fractures remain stable - even initially non-displaced fractures can displace during healing, requiring close monitoring 4
- Monitor for skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 4
Surgical Considerations if Conservative Treatment Fails
If conservative management fails after an average of 75 days (typically due to limited motion or persistent pain), delayed excision of the fracture fragment produces favorable outcomes 2. Surgical repair with bone anchor fixation has shown excellent results in pediatric patients when necessary, with full range of motion achievable within 6 weeks 6. However, nearly all stable PIP joint volar plate avulsion fractures should be attempted conservatively first 2.