How should a volar plate injury of the finger be initially managed non‑operatively (splinting, nonsteroidal anti‑inflammatory drug therapy, and rehabilitation), and what criteria indicate the need for surgical intervention?

Volar Plate Injury Management

Initial Non-Operative Management

For stable volar plate injuries without joint dislocation, begin immediate active mobilization with minimal splinting—this is the single most critical intervention to prevent finger stiffness and achieves excellent outcomes in 98% of cases. 1, 2

Immediate Assessment and Imaging

• Obtain 3-view radiographs of the injured finger immediately to differentiate between pure ligamentous injury and avulsion fractures, and to identify surgical indications 3, 1
• Do not delay radiographs, as this can lead to unreliable exclusion of fractures requiring surgery 4
• MRI is useful for evaluating volar plate soft-tissue injuries when clinical examination is equivocal, but is not routinely indicated for acute injury 5, 1

Conservative Treatment Protocol for Stable Injuries

Splinting approach:

• Apply a volar short arm splint or dorsal block splint initially for comfort, but prioritize early active motion over prolonged immobilization 1
• Dorsal block splinting at neutral position (0°) is superior to 30° flexion, as it prevents flexion deformities without increasing hyperextensibility 6
• Buddy taping is equally effective as extension block splinting for stable injuries and is faster, easier, and more flexible to use 7
• Immobilization duration should be minimal—typically 2-3 weeks maximum for stable injuries 1

Critical rehabilitation principle:

• Begin active finger motion exercises immediately for all joints (PIP and MCP), which is the single most critical intervention to prevent finger stiffness 4, 1
• Finger motion does not adversely affect adequately stabilized fractures 1
• Home exercise programs moving fingers through complete range of motion are effective and minimize stiffness risk 3

Pain Management

• Use topical NSAIDs over oral NSAIDs for safety reasons, with oral NSAIDs used for limited duration if needed 4
• Apply ice-water mixture for 10-20 minutes with a thin towel barrier to reduce swelling 4
• Avoid heat application initially 4

Surgical Indications

Immediate surgical referral is required when radiographs demonstrate any of the following:

• Bony avulsion fracture involving ≥1/3 of the PIP joint articular surface 4, 3, 1
• Palmar (volar) subluxation of the middle phalanx on lateral view 4, 3
• Interfragmentary gap >3mm 4, 3
• Displacement >3mm 3, 1
• Dorsal tilt >10° 1
• Open injury 4
• Joint dislocation at time of injury (associated with higher failure rate of conservative treatment) 8

Evidence for Surgical Criteria

The American College of Radiology emphasizes that involvement of more than one-third of the articular surface specifically necessitates operative fixation to prevent long-term complications such as persistent extensor lag or joint instability 4. A 2020 study found that the presence of joint dislocation and greater displacement and rotation of fragments are associated with failure of conservative treatment 8.

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 1
• Do not immobilize unaffected fingers, as this causes unnecessary hand stiffness 1
• Uninterrupted immobilization is essential when splinting is used: Even brief removal of the splint can restart the healing timeline 4
• Do not attempt to straighten the finger manually before proper evaluation and splinting 4

Follow-Up Protocol

• Obtain radiographs at 3 weeks to assess healing and alignment 1
• Final radiographic assessment when immobilization is discontinued 1
• Re-evaluate immediately if unremitting pain develops (VAS >6), as this may indicate inadequate fixation, pulley system injury, tendon adhesions, or re-rupture 4, 3, 1
• If range of motion deteriorates or new symptoms develop, reevaluate immediately 1

Delayed Surgical Management

For failed conservative treatment (persistent pain or limited motion after 75 days average), delayed excision of the fracture fragment results in favorable outcomes with reduced pain and increased range of motion, and postoperative protection of the joint is not necessary 8. This supports considering conservative treatment first in almost all volar plate avulsion fractures of stable PIP joints 8.

Outcome Expectations

• Excellent or good outcomes are achieved in 98% of cases with early active mobilization 2
• The size and displacement of the avulsed fragment do not affect outcome in stable joints 1, 2
• Patients presenting more than 3 weeks from injury have worse outcomes, emphasizing the importance of early mobilization 2