Volar plate injuries of the PIP joint in children are one of those diagnoses that, at first glance, seem minor. A swollen, painful finger, held slightly semi-flexed, an X-ray showing a small volar bone fragment at the base of the middle phalanx. Yet, if managed poorly, these injuries can lead to stiffness, residual pain, or incomplete flexion recovery [1].
The review published in HAND is particularly useful because it attempts to bring order to a topic where, in practice, there's a tendency to swing between two opposite errors: trivializing too much or operating too frequently [1].
For parents and non-pediatric orthopedic surgeons, the typical picture is often this: a blunt hyperextension injury to the finger, very often during sports or play, for example, a ball hitting the fingertip and forcing it abruptly backward. The review indeed reminds us that PIP hyperextension injuries represent a significant portion of hand traumas in pediatric age, and that in older age groups, sports are one of the most frequent mechanisms [1].
It's the classic finger that "bends backward," hurts immediately, swells rapidly, and the child moves it little due to discomfort.
On X-ray, in these cases, the famous volar fragment often appears: small, but not irrelevant for that reason. The point, however, is that the fragment itself does not determine the treatment. The more useful question is another: how large is the joint involvement and how stable is the PIP? [1]
The review included 25 studies, totaling 268 patients aged 3 to 17 years, and shows a fairly consistent message: when the injury involves less than 30% of the articular surface, and is classifiable as Eaton I or II or as stable according to Keifhaber-Stern, non-surgical treatment leads to excellent results, with positive outcomes in 99.5% of reported cases [1].
Conversely, when the articular involvement exceeds 30%, or the injury is classified as Eaton IIIa/IIIb or unstable, surgical treatment more often comes into play [1].
This is also the most useful passage in discussions with parents. Because the radiographic finding can be frightening: seeing a "detached piece" immediately suggests something that needs to be fixed. In reality, in stable cases, the small volar fragment is often a sign of an injury that can heal very well without surgery, provided the finger is well evaluated, centered, and followed correctly [1].
The review also helps to understand how this injury is conservatively treated. In the included acute non-surgical cases, the main methods were splinting and strapping: approximately 59.8% of patients were treated with splints (often aluminum or extension-block), approximately 37.7% with strapping/buddy strapping, and a small proportion with combinations of the two [1]. In some series, protected or early mobilization was also associated, indicating that the goal is not to immobilize "as much as possible," but to protect the PIP without turning it into a stiff joint [1].
This is a very important point for anyone seeing the child initially. If the finger is stable, the fragment is small, and the joint remains well-aligned, conservative treatment is by no means a "weak" choice: it is often the correct choice. The real risk, in simple cases, is not failing to operate. The risk is treating inaccurately, losing follow-up, or immobilizing a finger for too long, which will then struggle to regain movement [1].
In the clinic, a very typical scene often occurs: a boy gets injured playing basketball or soccer, a ball hits the fingertip, significant swelling at the PIP, X-ray with a small volar fragment, parents asking if "a piece of bone has broken off" and if it needs to be put back. This is precisely where this review becomes useful. Because it allows explaining that yes, the fragment exists, but the decision does not depend solely on its presence. It depends above all on stability, joint congruity, and the proportion of the involved surface [1].
Surgical intervention naturally remains important in worse cases. The authors report that more extensive or unstable injuries, often with greater articular involvement and poorer control of PIP centering, were treated with reduction and internal fixation, with good but, on average, inferior outcomes compared to the conservative group (85.7% positive outcomes) [1]. This does not mean that surgery "fares worse"; rather, it means that surgery comes into play in more severe cases.
From a practical point of view, therefore, the message is quite clear:
- hyperextension trauma + small volar fragment + stable PIP = often conservative treatment;
- larger fragment, instability, or significant articular involvement = more serious surgical evaluation [1].
The limitations of the review should still be remembered: the literature is heterogeneous, with many retrospective studies, not always uniform definitions of stability and outcome, and varying follow-up periods across case series [1]. It is not a definitive guideline, but it is a good clinical compass.
If I had to summarize the message in a single sentence, I would say this: in pediatric PIP volar plate avulsion fractures, the small volar fragment is not automatically a surgical indication. In stable cases, after the classic hyperextension trauma from a ball or fall, conservative treatment is often not only sufficient but also yields the best results [1].
Disclaimer
This content is for informational purposes only and does not replace an individual clinical evaluation.
References
[1] Choi H, Moon SH, Lee H, Barnes SP, Ma Y, Jester A, Al-Ani S. Management of Pediatric Volar Plate Avulsion Fractures of the Proximal Interphalangeal Joint: A Systematic Review. HAND. 2025;20(5):664-674. doi:10.1177/15589447241231308. PMID: 38380839. PMCID: PMC11571450.
