Volar plate avulsions of the PIP are common after hyperextension trauma to the finger, often during sports or play. X-rays may show a small volar bone fragment at the base of the middle phalanx. [1]
The presence of the fragment alone does not determine treatment. The percentage of articular surface involved and the stability of the proximal interphalangeal joint are most important.
What the Review Shows
A systematic review published in HAND included 25 studies and 268 patients between 3 and 17 years old. In injuries involving less than 30% of the articular surface, classified as Eaton I-II or stable according to Keifhaber-Stern, non-surgical treatment was associated with positive outcomes in 99.5% of reported cases. [1]
When articular involvement exceeded 30% or the injury was classified as Eaton IIIa/IIIb or unstable, surgery was used more often. [1]
How Stable Forms Are Treated
In non-surgical cases, splints and buddy strapping were primarily used, often with protected or early mobilization. [1]
The goal is to protect the PIP without immobilizing it more than necessary. Prolonged stiffness can become a significant problem even after an initially small injury.
When More Attention Is Needed
A large fragment, subluxation, an unstable joint, or greater articular involvement require a different approach. In these cases, reduction and fixation may be necessary to restore joint congruity. [1]
The surgically treated group in the review had positive outcomes in 85.7% of cases. This data should not be directly compared with that of the conservative group, because surgery was used in more severe cases. [1]
Clinical Assessment Matters as Much as X-rays
A swollen and painful finger after being hit by a ball may have a small avulsion and still remain stable. In these cases, conservative management is often sufficient.
However, it is useful to re-evaluate the child if the finger remains very stiff, if the pain does not improve, if the joint appears unstable, or if the X-ray shows a larger articular involvement than initially suggested by the trauma.
Limitations of the Literature
The studies included in the review are heterogeneous and predominantly retrospective. Definitions of stability, duration of immobilization, and outcome criteria vary. [1]
The most useful message is therefore a clinical one: in stable injuries, conservative treatment works very well; in unstable forms or those with greater articular involvement, surgical indication becomes more concrete.
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.
