Volar Plate Injury

The patient most commonly presents with pain and swelling at the PIP joint. The mechanism of injury is usually PIP joint hyperextension combined with some degree of longitudinal compression, such as when a fingertip is struck by a ball.³ This can result in dislocation.

Crush injuries of the PIP joint can also result in partial or complete volar plate rupture. Volar plate injury often occurs with concomitant avulsion fracture, most commonly at the volar base of the middle phalanx, and/or subluxation/dislocation. Dorsal and lateral dislocations are most commonly associated with volar plate injury. Practitioners should be aware the joint may have been reduced prior to presentation. History of dislocation is important in determining stability.¹

With significant longitudinal force, the volar lip of the middle phalanx may be sheared off or impacted, producing a fracture-dislocation. In some instances of dislocation, the volar plate ruptures and can become stuck between the head of the proximal phalanx and the base of the middle phalanx. This results in an irreducible dislocation that requires operative treatment.²

Long term treatment will depend on stability. In the ED, all injuries should be splinted in an extension blocking splint or buddy taped. Neither a blocking splint nor buddy taping has proven to be superior in milder cases of volar plate injury.⁵

Although, splinting in a slight bit of flexion is often better because they tend to be very tender injuries. A period of immobilization will help partial injuries heal faster and be more comfortable for the patient - buddy tape is not usually recommended.

The presence of an avulsion fracture involving >40% of the joint surface necessitates a hand surgeon referral as these are unstable.¹

Reduction of dislocations should be done in the ED.

• A mild hyperextension deformity typically reduces very easily under a digital block with a very small amount traction and volar translation or pressure.

• In a bayonet dislocation, a moment of extension should be applied to the middle phalanx, and the examiner’s thumb can be used to hook the base of the middle phalanx back over the head of the proximal phalanx. Pure longitudinal traction can trap the condyles by the collateral ligaments and pull the volar plate into the joint, turning a reducible dislocation into an irreducible dislocation.