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VOLAR PLATE RUPTURE

Introduction

The volar plate is a very strong and dense ligamentous structure located on the palmar surface of metacarpophalangeal (MP) and interphalangeal (IP) joints of all five digits.  The volar plate provides stability and limits passive hyperextension.1 Injuries to the volar plate are common and often considered an example of the “unseen” forces that underlie many hand injuries. Hyperextension of a finger from participation in ball sports, especially basketball and football, is most frequent cause of volar plate injuries. 2,3 Treatment for volar plate injuries is predominantly conservative and should include immediate mobilization, although surgical intervention may be necessary in certain severe unstable and/or chronic cases. 3

Pathophysiology

  • The most common mechanism for volar plate injuries is hyperextension of the proximal interphalangeal (PIP) joint, resulting in a sprain or rupture
    • Hyperextension most often results from the force of a ball in sports involving the hands—particularly basketball and football—as well as from a fall on an outstretched hand (FOOSH)
    • Volar plate injuries may also occur from a direct crushing force or with anterior or dorsal dislocation of the PIP joint2
    • The majority of volar plate injuries affect the ring, index, and long fingers and are seen in younger athletes2,3
    • Complete volar plate and collateral rupture may result from forced, sudden hyperextension or occasionally, crush injuries of the PIP joint
      • In most instances, volar plate rupture occurs distally at the weaker insertion site at the base of the middle phalanx; the proximal stronger checkrein ligaments rarely rupture.4  The attachments to the accessory collateral ligaments help strenthen the proximal origin of the volar plate.7,8
      • When a rupture occurs at the distal attachment of the volar plate, a chip of bone may be avulsed from the base of the middle phalanx at the insertion of the plate
      • Volar plate avulsion fractures have been reported to occur when the middle phalanx is hyperextended up to 70-80° during the injury3

Related Anatomy

  • The volar plate is a small, strong, dense ligament composed of a multilayered condensation of fibrocartilaginous tissue that lies between the flexor tendons and the palmar PIP joint capsule of all five digits; it originates from the proximal phalanx and inserts onto the middle phalanx2,3
    • Distally, it is fibrocartilaginous and firmly attached to the volar lip of the base of the middle phalanx.  The fibrocartilaginous portion of the volar plate is thicker under the middle of the joint than it is at the actual insertion site on the base of the middle phalanx.
    • On the lateral aspects of the distal attachment, the ligament is thicker where it fuses with the fibers of the accessory collateral ligament
    • Proximally, the volar plate is more elastic, inserting on the proximal phalanx as two lateral bands, the checkrein ligaments
    • The central portion of the plate is not attached to the proximal phalanx2
    • The volar plate serves several functions:
      • It forms the floor of the PIP joint and provides crucial stability against hyperextension, lateral displacement, and torsional forces
      • It acts as a meniscus between the middle phalangeal base and proximal phalangeal head
      • It forms part of the intracavity lining of the PIP joint
      • It is lined palmarly by a thin tenosynovium and provides a smooth gliding surface for the flexor tendon5

Incidence and Related Conditions

  • The proportion of volar plate ruptures that do not involve an avulsion fracture is difficult to estimate from the literature3
  • Accessory collateral ligament tear
  • Phalanx fracture
  • Avulsion fracture from the base of the middle phalanx
  • PIP joint subluxation and dislocation 

Differential Diagnosis

  • PIP joint subluxation or dislocation
  • Phalanx fracture
  • Contusion
  • Flexor or extensor tendon injury
  • Infection
ICD-10 Codes

  • VOLAR PLATE RUPTURE

    Diagnostic Guide Name

    VOLAR PLATE RUPTURE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    VOLAR PLATE RUPTURE, MCP, PIP and DIP FINGER    
    - INDEX S63.431_S63.430_ 
    - MIDDLE S63.433_S63.432_ 
    - RING S63.435_S63.434_ 
    - LITTLE S63.437_S63.436_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Volar Plate Injuries
  • Volar plate rupture right fifth finger chronic
    Volar plate rupture right fifth finger chronic
  • Volar plate rupture right fifth finger PIP joint during volar plate stress testing
    Volar plate rupture right fifth finger PIP joint during volar plate stress testing
  • Volar plate rupture left thumb MP joint during volar plate stress testing
    Volar plate rupture left thumb MP joint during volar plate stress testing
  • Volar plate rupture right ring finger PIP joint with RCL injury (arrow)
    Volar plate rupture right ring finger PIP joint with RCL injury (arrow)
  • Swan neck deformity secondary to chronic volar plate rupture right long finger PIP joint
    Swan neck deformity secondary to chronic volar plate rupture right long finger PIP joint
  • Swan neck deformity secondary to chronic volar plate rupture left long finger PIP joint
    Swan neck deformity secondary to chronic volar plate rupture left long finger PIP joint
Symptoms
History of finger trauma
Swollen painful joint especially on the palmar aspect
Bruising around a joint decreased motion
PIP joint instability (especially hyperextension) in chronic cases
Typical History

The typical patient is a 28-year-old, right-handed male basketball player. Upon trying to catch a fast forceful pass with his right hand that was out of his reach, he hyperextended his long finger and ruptured the volar plate of his PIP joint. After the injury, he experienced pain, tenderness, swelling and bruising directly over the PIP joint, as well as reduced range of motion of his long finger. He was unable to continue playing basketball.3,4

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
X-rays and Volar Plate Rupture
  • PIP joint stress X-ray demonstrating complete right volar plate rupture.
    PIP joint stress X-ray demonstrating complete right volar plate rupture.
Treatment Options
Conservative
  • Conservative treatment is recommended for the vast majority of volar plate injuries, especially if the volar plate is stable.4  The unstable volar plate injury results in a PIP joint that hyperextends beyond the degree of hyperextension seen in the uninjured opposite finger.  Stressing the volar plate causes marked tenderness.  A stable volar plate injury demonstrates no excessive hyperextension despite the tenderness caused by stress testing the plate in extension.
  • The main objective of treatment is to prevent a passive extension deficit of the PIP joint1
  • Immediate active and passive mobilization
  • Sustained extension-block splinting for up to 3 weeks and/or taping of the injured finger to a healthy neighboring finger (buddy taping)is ideal treatment.1
  • Exercise supervised by a hand therapist will improve the mobility and prevent stiffness, especially if the patient presents beyond 2 weeks3
Operative
  • Surgical treatment may be recommended for cases of significant joint instability, that fails treatment with extension block splinting.  When a volar plate rupture is with a large avulsion fracture, surgical treatment is indicated.3
  • Chronic volar plate injuries are treated with criss-cross volar tendon grafts or reattachment or repair of the volar plate or repair with a flexor digitorum superficialis slip tenodesis.2
  • Various methods of surgical repair have been suggested for volar plate injuries and accompanying dislocation:
    1. Simple closed reduction and immobilization in flexion
  • Various methods of surgical repair have been suggested for volar plate injuries and accompanying fractures:
    1. Open reduction and internal fixation
    2. K-wire fixation of the joint and any fragments
    3. A banjo splint using the 3-vector technique with three K-wires and traction
    4. Volar plate arthroplasty
Treatment Photos and Diagrams
Volar Plate Surgical Repair
  • Volar plate rupture right fifth finger chronic
    Volar plate rupture right fifth finger chronic
  • Volar plate rupture right fifth finger being repaired. Note arrow on edge of pad under button over which suture was tied.
    Volar plate rupture right fifth finger being repaired. Note arrow on edge of pad under button over which suture was tied.
  • Volar plate rupture right ring finger isolated and ready for repair (arrow)
    Volar plate rupture right ring finger isolated and ready for repair (arrow)
  • Volar plate rupture right ring finger after suturing with pull out and extra interval suture to accessory collateral or edge of the flexor pulley
    Volar plate rupture right ring finger after suturing with pull out and extra interval suture to accessory collateral or edge of the flexor pulley
  • Volar plate rupture left little finger being repaired. Flexors retracted. Keith needles for pullout suture in place. Volar plate edge seen (arrow).
    Volar plate rupture left little finger being repaired. Flexors retracted. Keith needles for pullout suture in place. Volar plate edge seen (arrow).
  • Volar plate rupture left little finger repair which is being augmented with a FDS slip (arrow).
    Volar plate rupture left little finger repair which is being augmented with a FDS slip (arrow).
  • Volar plate rupture left little finger repair which has been augmented with a FDS slip (arrow). The radial slip was passed under the flexors and sutured to the edge of the A-2 pulley or it can be secured with a bone anchor.
    Volar plate rupture left little finger repair which has been augmented with a FDS slip (arrow). The radial slip was passed under the flexors and sutured to the edge of the A-2 pulley or it can be secured with a bone anchor.
CPT Codes for Treatment Options

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Common Procedure Name
Volar plate repair/reconstruction
CPT Description
Repair and reconstruction, finger, volar plate, interphalangeal joint
CPT Code Number
26548
Common Procedure Name
Flexor digitorum superficialis tenodesis PIP joint
CPT Description
Tenodesis; of proximal interphalangeal joint, each joint
CPT Code Number
26471
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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CPT 2021 Professional Edition: Spiralbound

Complications
  • Scarring
  • Joint stiffness
  • Swan neck deformity
  • Traumatic arthritis
  • Flexion contracture
  • Recurrent subluxation of the PIP joint
  • Osteoarthritis
  • Active extension deficit
Outcomes
  • Good to excellent outcomes with a full range of pain-free movements have been reported for most patients treated conservatively3,6
  • Overall outcomes do not seem to be affected by the presence or absence of an avulsion fracture unless the fragment involves a large part of the joint surface and is displaced.1
  • For patients that undergo surgical intervention, range-of-motion outcomes appear to be better if surgery is performed within 4 weeks of the injury4
Key Educational Points
  • Volar plate test: passive flexion of the PIP joint produces anterior joint pain; can be used to detect a fracture3,4 
  • Radiographs are helpful for diagnosing avulsion fractures at the base of the volar middle phalanx and identifying PIP joint subluxation and dislocation
    • A lateral view of the affected finger usually reveals the avulsion fragment, but an oblique view is often required and should also be done routinely
    • Avulsion fractures rarely show up on a posteroanterior view and the diagnosis may be missed as a result3,4
    • Volar plate injuries do not look spectacular on radiographs3
  • Determination of the size of fracture fragments is typically made using the following terms:
    • A "dot" is a bony chip smaller than 1 mm in size
    • A "sliver" is a bony chip at least 1 mm long but with no appreciable width
    • A "fragment" is a larger chip measuring at least 1 mm in length and width2
  • Some researchers advise against surgical treatment because it leads to scarring and joint stiffness, with questionable benefits to the patient1,3
  • Understanding of the anatomy of the volar plate and use of classification systems can help to guide appropriate management4
  • Early diagnosis and proper therapeutic intervention is necessary to prevent complications2
References

Cited

  1. Adi M, Hidalgo Diaz JJ, Salazar Botero S, et al. Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture. Hand Surg Rehabil 2017;36(1):44-7. PMID: 28137442
  2. Nance EP Jr, Kaye JJ, Milek MA. Volar plate fractures. Radiology 1979;133(1):61-4. PMID: 472313
  3. Gaine WJ, Beardsmore J, Fahmy N. Early active mobilisation of volar plate avulsion fractures. Injury 1998;29(8):589-91. PMID: 10209589
  4. Pattni A, Jones M, Gujral S. Volar Plate Avulsion Injury. Eplasty 2016;16:ic22. PMID: 27313814
  5. Williams EH, McCarthy E, Bickel KD. The histologic anatomy of the volar plate. J Hand Surg Am 1998;23(5):805-10. PMID: 9763253
  6. Moutet F, Massart P, Frere G. Value of immediate mobilization in proximal interphalangeal volar plate avulsions [French]. Ann Chir Main 1984;3(3):221-6. PMID: 6529298
  7. Bowers WH, Wolf JW Jr, Nehil JL, Bittinger S. The proximal interphalangeal joint volar plate. I. An anatomic and biomechanical study. J Hand Surg Am1980;5(1):79-88. PMID: 7365222
  8. Bowers WH. The proximal interphalangeal joint volar plate. II: A clinical study of hyperextension injury. J Hand Surg Am1981;6(1):77-81. PMID: 7204922

New Articles

  1. Adi M, Hidalgo Diaz JJ, Salazar Botero S, et al. Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture. Hand Surg Rehabil 2017;36(1):44-47. PMID: 28137442
  2. Pattni A, Jones M, Gujral S. Volar Plate Avulsion Injury. Eplasty 2016;16:ic22. PMID: 27313814

Classics

  1. Nance EP Jr, Kaye JJ, Milek MA. Volar plate fractures. Radiology 1979;133(1):61-4. PMID: 472313
  2. Moutet F, Massart P, Frere G. Value of immediate mobilization in proximal interphalangeal volar plate avulsions [French]. Ann Chir Main 1984;3(3):221-6. PMID: 6529298
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