Early active mobilisation of volar plate avulsion fractures
Introduction
Volar plate injuries are an example of the ‘unseen’ forces which underly many hand injuries. An understanding of the soft tissue anatomy is important as these injuries do not look spectacular on radiographs. The functioning anatomy of the volar plate–collateral ligament complex and attachments at the interphalangeal joints was very well described in Bower's anatomical and biomechanical study of the proximal interphalangeal joint volar plate[1]. The volar plate avulsion fracture injury is usually caused by a hyperextension force, although a crush injury occasionally causes it. A volar or dorsal dislocation of the joint can also cause volar plate fractures[2]. In Eaton's classification of proximal interphalangeal joint injuries, the volar plate avulsion fracture is a type 1 injury and occurs when the middle phalanx is hyperextended up to 70–80 degrees at the time of injury. A longitudinal tear in the accessory collateral ligament can occur at the same time[3]. The bony avulsion nearly always occurs at the distal attachment[4], due to its fibrocartilaginous fusion with bone[5]. The proximal attachments of the volar plate (check reins) are strong and rarely torn. However, with slowly increasing volar forces, rupture of the proximal attachment occurs in cadaver models[1]. Diagnosis is based on the history of the mechanism of injury and clinical finding of a painful and swollen joint which is tender anteriorly. Passive flexion of the proximal interphalangeal joint produces anterior joint pain. This ‘volar plate test’ has been described to detect an ununited volar fracture which can remain symptomatic for many years[6]. A lateral radiograph usually reveals the avulsion fragment, although an oblique view is often required and should be done routinely. Rarely do these fractures show up on a posteroanterior view[4]and as a result the diagnosis may be missed. The proportion of volar plate ruptures which do not involve an avulsion fracture is difficult to estimate from the literature.
The recommended treatment varies widely. Late complications of this injury are flexion contracture, recurrent subluxations, swan-neck deformity and traumatic arthritis.
Section snippets
Method
In this unit hand injuries are managed jointly by the hand surgeons and two dedicated hand physiotherapists. One hundred and ninety-two consecutive patients were enlisted in the prospective study. Joint dislocations and unstable joints were excluded. The final follow up proformas were completed by an independent examiner.
All stable volar plate injuries were managed with immediate mobilisation. If progress was slow, and the volar proximal interphalangeal joint skin crease was ill defined at 2
Results
Out of the 192 patients, 162 were followed up for at least 1 year representing 166 volar plate fractures (three patients with two fractures). Twelve patients failed to attend after the initial visit. Sixteen patients failed to turn up for review at one year and were excluded. Two patients changed address and were untraceable. The average age was 28 years and 59 per cent were male. Sports injuries accounted for 92.8 per cent of the patients — 78 per cent as a result of ball games (the majority at
Discussion
Management of volar plate fractures varies from early mobilisation to surgical repair of the volar plate. Generally, splinting for varying periods up to three weeks and supervised hand physiotherapy is advocated. Surgical treatment has been advocated for cases of joint instability and where a large fragment has been avulsed. As it is basically a fibrocartilaginous injury with some degree of accessory ligament damage, it is not surprising that the size or displacement of the avulsed fragment
Conclusion
We advocate immediate active and passive mobilisation within the patient's pain tolerance in stable interphalangeal volar plate avulsion injuries, irrespective of time of presentation. Patients who present within 2 weeks do well with minimal or no physiotherapy management other than instruction at initial consultation. Operative intervention leads to scarring and joint stiffness with no real benefit to the patient.
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Cited by (23)
Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment
2023, Journal of Hand SurgeryVolar Plate Injuries of the Proximal Interphalangeal Joint
2021, Journal for Nurse PractitionersCitation Excerpt :Unless VPIs are identified early and treated appropriately they can result in loss of function and deformity of the affected finger(s). Undertreated or mismanaged VPIs can lead to complications such as flexion contracture, recurrent subluxations, or swan-neck deformity.5 Some VPIs are isolated injuries, whereas others can be an aspect of a more significant injury, such as a dislocated finger.
Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review
2017, Journal of PhysiotherapyCitation Excerpt :When added to the trials in the original review, 23 articles27–35,43–56 were included; these comprised 22 separate trials27–35,43–45,47–56 because one article46 reported follow-up data (Figure 1). Twenty-two trials were excluded for the following reasons: trial protocol only (n = 1);41 upper limb rehabilitation not evaluated (n = 2);36,37 exercise was not the intervention that was evaluated (n = 4);38–40,42 not (quasi-) randomised, controlled trials (n = 5);57–61 not in English (n = 1);62 published only as an abstract (n = 1);63 or insufficient information about the exercise therapy intervention (n = 8).64–71 PEDro scores ranged from 2 to 8 out of 10, with a median score of 5 (Table 1).
Management of proximal interphalangeal joint hyperextension injuries: A randomized controlled trial
2014, Journal of Hand SurgeryCitation Excerpt :These results confirm similar findings that suggest that protected immediate mobilization of a stable VP injury is beneficial compared with immobilization.6,7 Specifically, excellent outcome is demonstrated in more than 90% of the patients in all protocols involving immediate protective mobilization.7,12 Conversely, immobilization of the PIP joint seems to be associated with slightly worse outcome.6,9,13
Exercise reduces impairment and improves activity in people after some upper limb fractures: A systematic review
2011, Journal of PhysiotherapyCitation Excerpt :The other 15 studies obtained as full text were excluded. Five were not randomised or quasi-randomised controlled trials (Altissimi et al 1986, Amirfeyz and Sarangi 2008, Clifford, 1980, Liow et al 2002, MacDermid et al 2001), one was not available in English (Grønlund et al 1990), one was published only as an abstract (Bache et al 2000), and eight had insufficient information about the exercise therapy intervention (Davis and Buchanan, 1987, de Bruijn, 1987, Dias et al 1987, Gaine et al 1998, Lozano Calderón et al 2008, McAuliffe et al 1987, Millett and Rushton, 1995, Oskarsson et al 1997). Design: A single trial evaluated the effects of exercise and home advice compared to a no-intervention control group in patients with a distal radius fractures (Kay et al 2008).
Phalangeal fractures of the hand
2010, Clinical RadiologyCitation Excerpt :With more articular surface involvement in a volar plate fracture, the balance is shifted towards operative intervention as the joint becomes increasingly unstable.15 A small fracture may be treated conservatively as it is intrinsically stable.18,19 When the fracture involves over 30–50% of the volar articular surface, the stabilizing collateral ligaments are attached to the avulsed volar fragment of bone, resulting in joint instability from dorsal subluxation of the middle phalanx.20