01Approach to the Critical Patient/attcp27

Alarm Features

›Alarm features requiring urgent action

›Open dislocation with skin breach overlying PIP joint

›Risk of septic arthritis and osteomyelitis

›Urgent orthopaedic or hand surgery consultation

›Irreducible dislocation after closed reduction attempt

›Suspect soft tissue interposition (volar plate, flexor tendon)

›Surgical reduction required

›Avulsion fracture involving greater than 30% of articular surface

›Indicates joint instability

›Hand surgery consultation required

›Vascular compromise of digit

›Absent capillary refill, pallor, or dusky discoloration

›Immediate vascular surgery or hand surgery consultation

Stabilization Priorities

›Stabilization and initial management priorities

›Neurovascular assessment of affected digit before and after any manipulation

›Capillary refill, two-point discrimination, digital pulses

›Document baseline before procedural analgesia

›Analgesia prior to reduction

›Digital nerve block with lidocaine 1-2% without epinephrine preferred

›May use lidocaine with epinephrine per current evidence (safe in digits)

›Closed reduction of acute PIP dorsal dislocation

›Apply longitudinal traction with gentle volar pressure on middle phalanx

›Confirm reduction with clinical exam and post-reduction radiograph

›Post-reduction assessment

›Repeat neurovascular exam

›Assess active range of motion and joint stability

02History/hx31

Mechanism of Injury

›Mechanism of injury

›Hyperextension force to the fingertip

›Ball striking outstretched finger (basketball, volleyball, football)

›Fall on outstretched hand

›Workplace machinery or falls

›Associated popping or snapping sensation at time of injury

›Forced dorsiflexion beyond physiologic range

Symptom Characterization

›Symptom characterization

›Acute onset of PIP joint pain immediately following injury

›Swelling at PIP joint

›Difficulty bending the finger

›Inability to make a full fist

›"Jammed finger" description by patient

Timing and Chronicity

›Timing and chronicity

›Time elapsed since injury

›Delayed presentation greater than 3 weeks associated with worse outcomes

›Chronic injuries more difficult to reduce and have higher surgical rates

›Prior episodes of "jammed finger" at same joint

Important Negatives

›Important negatives

›Numbness or tingling in affected digit (suggests neurovascular compromise)

›Inability to extend PIP joint against resistance (suggests central slip disruption)

›Open wound or skin break overlying joint

›Fever or systemic symptoms (concern for septic joint)

03Physical Exam/exam36

Inspection

›Inspection findings

›Swelling and ecchymosis at PIP joint

›Deformity or malalignment of digit

›Comparison to contralateral hand for baseline assessment

›Open wound or skin disruption overlying joint

›Nail bed injury or subungual hematoma

Palpation

›Palpation findings

›Focal tenderness over volar aspect of PIP joint (hallmark finding)

›Tenderness over lateral aspects (collateral ligament involvement)

›Tenderness over dorsal PIP joint (central slip or dorsal capsule)

›Bony step-off or crepitus suggesting fracture

Range of Motion

›Range of motion assessment

›Active flexion and extension of PIP joint

›Active flexion and extension of DIP joint

›Comparison to contralateral digit

›Pain with terminal extension suggests volar plate or flexor injury

Stability Testing

›Stability testing

›Lateral stress test in full extension (radial and ulnar collateral ligaments)

›Repeat at 30 degrees of flexion to isolate collateral ligaments

›Laxity greater than contralateral side indicates collateral tear

›Hyperextension stress test

›Passive hyperextension of PIP joint

›Increased laxity compared to contralateral side indicates volar plate incompetence

›Elson test for central slip integrity

04Differential Diagnosis/ddx42

PIP Joint Dislocations

›PIP joint dislocations

›Dorsal dislocation of PIP joint

›Most common PIP joint dislocation

›Middle phalanx displaces dorsal to proximal phalanx

›Almost always associated with volar plate disruption

›Volar dislocation of PIP joint

›Less common, higher surgical rate

›Risk of central slip and collateral ligament injury

›Requires hand surgery consultation

›Lateral dislocation of PIP joint

›Associated with collateral ligament rupture

›May require surgical repair if complete tear

Tendon Injuries

›Tendon injuries at PIP joint

›Central slip disruption

›Inability to actively extend PIP against resistance

›Risk of Boutonniere deformity if missed

›Elson test positive

›Flexor digitorum superficialis (FDS) injury

›Weakness or inability of PIP flexion

›Isolate FDS by holding adjacent fingers in extension

Fractures

›Fractures at PIP joint

›Middle phalanx fracture (base, shaft, or condyle)

›May coexist with volar plate injury

›Assess on radiograph for displacement

›Proximal phalanx head or condyle fracture

05Laboratory Tests/lt18

Routine Labs

›Routine laboratory evaluation

›Routine labs not indicated for isolated volar plate injury

›No CBC, metabolic panel, or coagulation studies needed for uncomplicated cases

Infection Workup

›Infection workup (if open wound, fever, or septic joint suspected)

›Complete blood count

›Leukocytosis suggests infection or septic joint

›Normal WBC does not exclude septic arthritis

›Erythrocyte sedimentation rate (ESR)

›Elevated in septic arthritis and inflammatory conditions

›C-reactive protein (CRP)

›More sensitive early marker than ESR for joint infection

›Joint aspiration cell count and differential

›White blood cell count greater than 50,000 cells/microL suggests septic arthritis

›Gram stain and culture essential for organism identification

Pre-Operative Labs

›Pre-operative laboratory evaluation (if surgical intervention planned)

›CBC, basic metabolic panel as per anesthesia requirements

›Coagulation studies if on anticoagulants or bleeding history

›Type and screen not typically required for hand procedures

06Diagnostic Tests/dt69

Scoring Systems

›Severity grading system for volar plate injuries

›Grade I (sprain)

›Volar plate stretched but structurally intact

›Stable joint on stress testing

›No avulsion fracture or minimal periosteal reaction

›Grade II (partial tear)

›Volar plate partially torn

›Possible small avulsion fracture fragment less than 30% of articular surface

›Joint stable after reduction

›Grade III (complete tear or fracture-dislocation)

›Complete volar plate disruption

›Avulsion fracture involving greater than 30% of articular surface

›Persistent subluxation on lateral radiograph

›Unstable joint requiring surgical referral

MRI

›MRI for volar plate injury

›Indications for MRI

›Chronic PIP pain without clear diagnosis on radiograph

›Suspected soft tissue injury not visualized on plain film

›Pre-operative planning for complex ligamentous reconstruction

›Suspicion of complete multi-ligament injury

›MRI findings

›Volar plate discontinuity or increased T2 signal (tear or edema)

›Collateral ligament integrity assessment

›Flexor and extensor tendon evaluation

›Bone marrow edema at avulsion site

›Limitations

›Rarely indicated acutely in the emergency setting

›Reserve for diagnostic uncertainty or surgical planning

CT

›CT for volar plate injury

›Indications for CT

›Complex intra-articular fractures requiring surgical planning

›Comminuted fractures of middle or proximal phalanx

›Assessment of articular surface involvement when plain film is inadequate

›CT findings

›Fragment size and articular surface involvement quantified

›Joint congruity and subluxation on axial and sagittal reconstructions

›Associated phalangeal fracture characterization

›Limitations

›Not required for routine volar plate injury diagnosis

›Reserve for pre-operative assessment of complex fractures

Ultrasound

›Ultrasound for volar plate injury

›Point-of-care ultrasound (POCUS) indications

›Dynamic assessment of volar plate integrity

›Assessment of joint stability with stress maneuvers

›Detection of avulsion fragment not seen on plain film

›Evaluation of collateral ligament and flexor tendon integrity

›POCUS technique

›High-frequency linear transducer (10-18 MHz)

›Volar longitudinal view of PIP joint

›Dynamic stress assessment with hyperextension maneuver

›POCUS findings

›Volar plate discontinuity or hypoechoic gap indicates tear

›Hyperechoic avulsion fragment with posterior acoustic shadowing

›Increased joint space with stress indicates instability

›Limitations

›Operator-dependent modality

›Plain radiograph remains first-line for fracture assessment

Plain Radiography

›Plain radiography (first-line imaging)

›Standard views

›AP, lateral, and oblique views of affected finger

›True lateral view is critical for diagnosis

›Key findings on lateral view

›Small avulsion fragment at volar base of middle phalanx (pathognomonic for volar plate avulsion)

›Joint subluxation or dislocation

›Fragment size relative to articular surface (greater than 30% indicates instability)

›Post-reduction radiographs

›Mandatory after any closed reduction

›Confirm joint congruity and fragment position

›Persistent subluxation on post-reduction film indicates surgical referral

07Disposition/dispo28

Discharge Criteria

›Discharge criteria

›Stable Grade I or Grade II volar plate injury

›Successful closed reduction with confirmed joint congruity on post-reduction radiograph

›Intact neurovascular status post-reduction

›No evidence of central slip disruption

›Fragment less than 30% of articular surface on post-reduction radiograph

›Ability to tolerate pain with oral analgesia

›Reliable patient with capacity for compliance with splinting instructions

Admission Criteria

›Admission criteria

›Open fracture-dislocation requiring operative intervention

›Polytrauma with associated injuries requiring admission

›Vascular compromise not resolved with reduction

›Septic arthritis requiring IV antibiotics and surgical washout

Orthopaedic or Hand Surgery Consultation

›Indications for immediate consultation

›Avulsion fracture involving greater than 30% of articular surface

›Irreducible dislocation

›Open dislocation or fracture

›Suspected central slip disruption (risk of Boutonniere deformity)

›Persistent subluxation after reduction

›Lateral or volar dislocation

›Dislocation greater than 3 weeks old

›Vascular compromise of digit

Follow-Up

›Follow-up planning

›First follow-up at 2 weeks for repeat radiograph and clinical assessment

08Treatment/t63

Analgesia

›Analgesia

›NSAIDs (first-line for pain and swelling)

›Ibuprofen 400-600 mg PO every 6-8 hours with food

›Maximum 2400 mg per day

›Avoid if renal impairment or GI contraindication

›Naproxen 500 mg PO twice daily

›Maximum 1000 mg per day

›Acetaminophen as adjunct or alternative to NSAIDs

›500-1000 mg PO every 6 hours

›Maximum 4000 mg per day (3000 mg per day in elderly)

›Ice application for first 48-72 hours to reduce swelling

›Elevation of hand above heart level

Digital Nerve Block

›Digital nerve block for reduction or significant pain

›Lidocaine 1-2% without epinephrine (traditional approach)

›2-4 mL total per digital block (1-2 mL per side)

›May use lidocaine with epinephrine per current evidence (safe in digits)

›Technique

›Dorsal web space approach or volar approach

›Block radial and ulnar digital nerves at base of proximal phalanx

›Onset within 5-10 minutes

›Bupivacaine 0.25-0.5% for longer-acting analgesia

›Duration of action 4-8 hours

›Useful for post-reduction comfort

Closed Reduction

›Closed reduction technique for PIP dorsal dislocation

›Apply longitudinal traction to middle phalanx

09Special Populations/sp46

Pregnancy

›Volar plate injury in pregnancy

›Diagnostic considerations

›Plain radiograph is safe with shielding of abdomen

›Radiation exposure from finger radiograph is negligible

›MRI preferred over CT for further imaging if needed

›Treatment modifications

›Acetaminophen preferred analgesic throughout pregnancy

›NSAIDs relatively contraindicated in third trimester (risk of premature ductus arteriosus closure)

›NSAIDs acceptable in first and second trimester with caution

›Splinting and buddy taping remain safe and effective in all trimesters

›No pregnancy-specific modification to reduction technique required

Geriatric

›Volar plate injury in geriatric patients

›Epidemiologic considerations

›Less common in elderly compared to young adults and athletes

›Falls are more common mechanism than sports injuries

›Higher rate of associated osteoporotic fractures

›Diagnostic considerations

›Lower threshold for CT if complex intra-articular fracture suspected

›Assess for concomitant wrist or forearm fracture (fall mechanism)

›Pre-existing arthritis may complicate assessment of joint integrity

›Treatment modifications

›NSAIDs used with caution

›Increased GI, renal, and cardiovascular risk in elderly

›Consider acetaminophen as primary analgesic

›Shortest effective NSAID duration if used

›Acetaminophen maximum 3000 mg per day in elderly

10Background/b40

Epidemiology

›Epidemiology of volar plate injury

›Most common mechanism: ball sports (basketball, volleyball, football, baseball)

›Second most common mechanism: falls and workplace incidents

›Most common demographic: adolescents and young adults participating in sports

›PIP joint dorsal dislocation is one of the most frequently seen hand injuries in emergency medicine

›Volar plate injury accompanies virtually all PIP dorsal dislocations

›Most injuries (approximately 98%) achieve excellent or good functional outcomes with conservative treatment

›Surgical intervention required in minority of cases (avulsion greater than 30% articular surface, irreducible dislocation)

Pathophysiology

›Pathophysiology of volar plate injury

›Anatomy

›Volar plate is a thick fibrocartilaginous ligament on palmar surface of PIP joint

›Proximal attachment: check-rein ligaments attach to proximal phalanx (flexible)

›Distal attachment: firm insertion into volar base of middle phalanx (rigid)

›Prevents PIP joint hyperextension

›Injury mechanism

›Hyperextension force exceeds volar plate tensile strength

›Volar plate avulses from distal insertion (middle phalanx) most commonly

›Avulsion may carry a bony fragment from volar base of middle phalanx

›Spectrum from stretch injury (Grade I) to complete tear with fracture (Grade III)

›Complications of missed or improperly treated injuries

›Flexion contracture (most common complication)

›Chronic PIP joint hyperextensibility (swan neck deformity)

›Recurrent instability

›Chronic pain and stiffness

›Full recovery may take 12-18 months

11Patient Discharge Instructions/pdi31

copy discharge instructions

›Volar plate injury discharge instructions

›Diagnosis and healing explanation

›Volar plate injury is a ligament sprain or tear at the middle knuckle (PIP joint) of the finger

›Most injuries heal well with proper splinting and gradual return to motion

›Swelling and stiffness at the knuckle may persist for weeks to months

›Full recovery can take 12-18 months in some cases

›Splint and buddy tape instructions

›Wear the splint as instructed for 2-3 weeks

›Do not remove the splint unless instructed by your doctor

›Buddy tape the injured finger to the adjacent finger for 3-6 weeks

›Buddy tape during all activity, including sports, until cleared by your doctor

›Pain management

›Take ibuprofen 400-600 mg every 6-8 hours as needed with food (if no contraindication)

›Alternatively take acetaminophen 500-1000 mg every 6 hours as needed

›Apply ice wrapped in cloth for 20 minutes at a time during first 48-72 hours

›Keep the hand elevated above heart level to reduce swelling

›Activity restrictions

›Avoid hyperextension activities during healing

›Do not return to ball sports without buddy taping and medical clearance

›Premature removal of splint risks chronic instability or flexion deformity

›Return to emergency department immediately for

›Increasing pain, swelling, or inability to move the finger

›New numbness, tingling, or color change in the finger

›Pale, blue, or dusky color of the fingertip

›Fever or discharge from any wound near the joint

›Finger locking or inability to straighten

›Recurrent dislocation or joint giving way

12References/r22

Guidelines and Key Sources

›Key references for volar plate injury

›Childress MA, Olivas J, Crutchfield A. Common Finger Fractures and Dislocations. American Family Physician. 2022. PMID 35704814

›Primary source for clinical management, alarm features, and surgical indications

›Supports conservative management for stable injuries

›Gaine WJ, Beardsmore J, Fahmy N. Early Active Mobilisation of Volar Plate Avulsion Fractures. Injury. 1998. PMID 10209589

›98% excellent or good outcomes with early active mobilization

›Supports protected early motion protocol

›Stanley EA, Seifman MA, Mills B, Fay P, Thomas DJ. Dorsal Block Splinting of Volar Plate Injuries at Neutral Position. Annals of Plastic Surgery. 2019. PMID 30882419

›Neutral position splinting associated with fewer flexion deformities

›Faster return to function compared to traditional 20-30 degree flexion splinting

›Weber DM, Kellenberger CJ, Meuli M. Conservative Treatment of Stable Volar Plate Injuries of the PIP Joint in Children and Adolescents. Pediatric Emergency Care. 2009. PMID 19755884

›Dorsal extension-block splint at 15 degrees for 10 days in pediatric patients

›Excellent outcomes without formal hand therapy in most cases

›Nance EP, Kaye JJ, Milek MA. Volar Plate Fractures. Radiology. 1979. PMID 472313

›True lateral radiograph is critical for diagnosis

›Avulsion fragment at volar base of middle phalanx is pathognomonic

›Lee S, Jung EY, Kim JY. Operative Treatment for Volar Plate Avulsion Fractures. Archives of Orthopaedic and Trauma Surgery. 2013. PMID 23892555

›Fragment excision and internal fixation show similar outcomes

›Surgical outcomes data for unstable injuries

›Currie KB, Tadisina KK, Mackinnon SE. Common Hand Conditions: A Review. JAMA. 2022

›Comprehensive review of hand conditions including PIP joint injuries

›Trigger finger and other PIP joint mimics discussed

Evidence & Review

Evidence & Review