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Volar Plate Tenderness

Exams and Signs

Historical Overview

  • Volar plate tenderness often stems from an injury at the proximal interphalangeal (PIP) joint. In 1939, Kaplan first discussed the pure extension injury at the PIP joint.1

Description

  • Patients experience tenderness on the volar plate, which forms the floor of the PIP joint. The volar plate becomes the main stabilizer to lateral deviation when the collateral ligaments are torn.2
  • As a result of a long lever arm and a highly congruent joint, allowing only a single level of motion, the PIP joint is susceptible to injury. It has limited laxity to neutralize angular, axial or rotational stresses.3
  • If a PIP joint injury is ignored or insufficiently splinted, this may result in chronic hyperextension deformities.1

Pathophysiology

  • A patient with volar plate tenderness from a PIP dislocation usually displays a noticeable deformity of the affected finger.2
  • Another cause of volar plate tenderness and swelling is a distal radius fracture.

Instructions

  1. Record the patient’s history, including any sports-related injuries. Ask the patient to rate how much pain s/he usually experiences in the affected finger on a scale from 1 to 10.
  2. Palpate the volar plate. Observe active flexion and extension.3
  3. Check for tenderness, swelling, stiffness and/or pain over the volar plate.
  4. Examine the contralateral finger for comparison.

Variations

  • To determine what treatment is needed, assess whether the PIP injury is a Type I, II or III.
  • Type I, dorsal PIP injuries, should be treated with immobilization of the joint.
  • Type II, complete dislocations, should be splinted in up to 30° of flexion.
  • Type III, with disruption of <30% of the volar articular surface, requires 3 weeks of dorsal block splinting.2

Related Signs and Tests

  • Volar plate stability
  • Range of motion (ROM)
  • Neurovascular exam
  • Plain radiographs

Diagnostic Performance Characteristics

  • To help verify the diagnosis of a PIP joint injury, use plain radiographs, including a true lateral of the PIP joint.2
  • Do not use other patients’ reactions as a comparison, because other patients may have different perceptions of similar tenderness and/or pain.
Definition of Positive Result
  • A positive result occurs when there is increased tenderness at the volar plate with pressure.
Definition of Negative Result
  • A negative result occurs when pressure does not cause increased tenderness at the volar plate.
Comments and Pearls
  • If operative treatment for PIP joint fractures/dislocations is needed, it is vital to obtain a concentric PIP joint reduction and restore joint stability.3
  • In volar plate arthroplasty, the volar plate is advanced into the middle phalanx and the PIP joint is stabilized.2
Diagnoses Associated with Exams and Signs
References
  1. Bowers WH. The proximal interphalangeal joint volar plate. II: A clinical study of hyperextension injury. J Hand Surg Am 1981;6(1):77-81. PMID: 7204922
  2. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012.
  3. Calfee RP, Sommerkamp TG. Fracture-dislocation about the finger joints. J Hand Surg 2009;34(6):1140-7. PMID: 19643295
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