Treatment of Minimally Displaced Volar Plate Avulsion Injury
Conservative treatment with immediate active mobilization is the recommended approach for minimally displaced volar plate avulsion fractures of the middle phalanx, regardless of fragment size, provided the PIP joint is stable without dislocation. 1, 2, 3
Initial Management Algorithm
Assess Joint Stability First
- Check for PIP joint dislocation or subluxation – the presence of joint dislocation is the strongest predictor of conservative treatment failure and may require surgical intervention 2
- Evaluate for displacement >3mm, dorsal tilt >10°, or substantial intra-articular involvement, which indicate instability requiring more rigid immobilization 1
- If the joint is stable (no dislocation, minimal displacement), proceed with conservative management 2, 3
Conservative Treatment Protocol
- Apply a volar short arm splint initially for comfort, but prioritize early active motion over prolonged immobilization 4, 1
- Begin active finger motion exercises immediately for all joints – this is the single most critical intervention to prevent finger stiffness, which is the most functionally disabling complication 5, 1, 6
- Finger motion does not adversely affect adequately stabilized fractures 5, 1
- Immobilization duration should be minimal – typically 2-3 weeks maximum for stable injuries 1, 3
Evidence Supporting Early Mobilization
The strongest evidence comes from a prospective study of 190 consecutive volar plate avulsion fractures managed with immediate active movement, achieving excellent or good outcomes in 98% of cases 3. Critically, the size and displacement of the avulsed fragment did not affect outcome in stable joints 3. This directly addresses your case of a "miniscule ossific fragment minimally displaced."
A more recent 2020 study identified that greater displacement and rotation of fragments (not fragment size) predict conservative treatment failure, along with the presence of joint dislocation 2. Since your case describes minimal displacement without mention of dislocation, conservative management is appropriate.
Follow-Up Protocol
- Obtain radiographs at 3 weeks to assess healing and alignment 1, 6
- Final radiographic assessment when immobilization is discontinued 1, 6
- If pain persists (VAS >6), range of motion deteriorates, or new symptoms develop, reevaluate immediately 5, 1
When Conservative Treatment Fails
Approximately 20% of cases may require delayed fragment excision if conservative treatment fails, typically after an average of 75 days 2. Indications for surgical intervention include:
- Persistent pain limiting function 2
- Significant flexion contracture (>30 degrees) 2
- Joint dislocation at time of injury 2
- Greater displacement or rotation of fragments 2
Delayed fragment excision produces favorable results without requiring postoperative joint protection, with increased range of motion and reduced pain 2. If surgery becomes necessary, hook plate fixation provides stable fixation allowing early active motion 7.
Critical Pitfalls to Avoid
- Do not over-immobilize – prolonged rigid splinting beyond 3-4 weeks dramatically increases finger stiffness and functional impairment without providing additional benefit 5, 1, 6
- Do not immobilize unaffected fingers – this causes unnecessary hand stiffness 6
- Patients presenting more than 3 weeks from injury have worse outcomes – early mobilization is time-sensitive 3
- Do not assume fragment size predicts outcome – stability of the joint and degree of displacement matter more than fragment size 2, 3
Special Consideration for Concomitant Injuries
If collateral ligament rupture is suspected (lateral joint instability, pain with lateral stress), outcomes remain favorable with surgical volar plate reattachment, though greater extension lag may occur 8. MRI can identify associated soft tissue injuries if clinical examination is equivocal 5.