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Three Part Question

In [adults with volar plate avulsion fractures] does [early mobilisation or splintage] lead to [superior functional outcome]?

Clinical Scenario

A thirty year-old man presents to the Emergency Department a few hours after a hyperextension injury to his index finger. Radiograph demonstrates an avulsion fracture at the volar plate of the proximal interphalangeal joint. You wonder whether splintage or early active mobilisation will lead to a better functional outcome.

Search Strategy

OVID Medline 1966 - February 2005
(exp Finger Joint/ OR exp Finger Injuries/ OR volar plate.mp. OR volar avulsion.mp.) AND (exp Splints/ OR splintage.mp. OR mobilisation.mp. OR exp Immobilization/ OR immobilisation.mp. OR conservative management.mp.) limit to human and english language
(volar plate.mp. OR Fingers/ OR exp Finger Joint/ OR proximal interphalangeal joint.mp. OR PIP joint.mp.) AND (exp Fractures/ OR exp Fractures, Closed/) AND (exp Early Ambulation/ OR mobilisation.mp. OR exp Immobilization/ OR strapping.mp. OR splint$.mp.) LIMIT to human and english language

Search Outcome

Altogether 355 papers were identified using the reported search, of which three were relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Phair IC; Quinton DN; Allen MJ 1989 UK	74 consecutive patients who had sustained a volar avulsion fracture at the PIP joints (size not greater than 2x2mm) and attended for review between 6 and 24 months after injury. Patients with radiological subluxation were excluded. 42 were treated by immobilisation in 30 degrees flexion with an aluminium splint for 1-7 weeks (average 3.1 weeks) and 32 were permitted to mobilise by neighbour strapping for 1-6 weeks (average 2.8 weeks).	Retrospective comparative study	Time to regain normal range of movement (weeks)	Mean 5.7 in neighbour strapping group (range 1-16); mean 8.9 in splintage group (range 2-24)	Retrospective Not planned interventions; patients seemingly assigned to different treatment groups at the initial treating surgeon's discretion, no randomisation No statistical analysis Six patients included following reduction of dorsal dislocation and may have had unstable joints Mobilisation only permitted within the restraints of neighbour strapping Assessments of functional outcome were subjective Functional outcome was assessed by the authors, which may have introduced bias No standardisation of interventions (large range in durations of strapping or immobilisation) No standardisation of review period (large range in time of review)
			Time to regain normal use (weeks)	Mean 6.8 in neighbour strapping group (range 2-24); mean 10.9 in splintage group (range 3-52)
			Functional outcome (excellent, good or poor)	31 (96.6%) 'excellent' in neighbour strapping group vs. 39 (93%) in splintage group
Gaine WJ; Beardsmore J; Fahmy N 1998 UK	192 consecutive patients seen at the Hand Clinic with volar plate avulsion fractures. Joint dislocations and unstable joints were excluded. 162 patients (with 166 fractures) were followed up for at least one year and were included in the analysis.	Prospective interventional trial	Functional outcome (excellent, good, poor or fair, assessed by an independent examiner)	142 patients (88%) reported excellent outcome (full range of pain-free movements); 17 patients (10%) reported good outcome (average 10 degrees PIP joint deformity), 3 patients fair result (intermittent pain & swelling).	Not a controlled trial Discrepancy with numbers: 162 patients with 166 fractures, but only three patients had two fractures Some patients also received ultrasound therapy but this was not standardised Only small fractures analysed but no mention of large fractures being excluded or acceptable objective size of fracture for inclusion Patients recruited having been referred to the Hand Clinic, which may have introduced bias. Patients may have been treated with splintage for variable periods before inclusion in the study (two-thirds of patients were seen within one week and a further fifth within two weeks)
Norregaard O; Jakobsen J; Nielsen KK 1987 Denmark	112 consecutive patients with hypertexension injuries to the PIP finger joints presenting to the Emergency Department Quasi-randomised (by dates) to receive aluminium splint immobilisation in the anatomical position for three weeks (56 patients) or no immobilisation with advice to mobilise within a few days (56 patients). Patients reviewed at six months and three years after injury	PRCT	Functional outcome in terms of residual symptoms, range of movement and deformity. Assessed at 6 months and 3 years	No significant differences between the two groups	Volar plate injuries diagnosed clinically, apparently without taking account of radiographic appearances No mention of exclusion criteria No sample size calculation; sample seems small Large proportion of patients lost to follow up (only 87 of 112 patients followed up at six months and 68 at three years; grade of severity only reported in 16 patients at three years). Unblinded assessment of outcomes No intention to treat analysis
			Grading of sequelae (mild, moderate or severe) at 3 years	No significant differences between the two groups

Comment(s)

There is a range of opinion as to the optimal treatment for small, stable volar plate avulsion fractures. Some advocate immobilisation with aluminium splints, others neighbour strapping and others early active mobilisation. Unfortunately there are no randomised controlled trials to compare the efficacy of these interventions. The three trials that were identified had significant weaknesses but they suggest that early mobilisation leads to acceptable functional outcome, which may be at least as good as following immobilisation. There is no evidence of harm following early mobilisation. However, the available evidence is insufficient to make an evidence-based recommendation for early active mobilisation instead of splintage.

Clinical Bottom Line

Local guidelines should be followed.

References

1. Phair IC; Quinton DN; Allen MJ The Conservative Management Of Volar Avulsion Fractures Of The PIP Joint Journal Of Hand Surgery 1989; 14B: 168-170
2. Gaine WJ; Beardsmore J; Fahmy N Early active mobilisation of volar plate avulsion fractures Injury 1998; 29 (8): 589-591
3. Norregaard O; Jakobsen J; Nielsen KK Hyperextension injuries of the PIP finger joint. Comparison of early motion and immobilization Acta Orthopaedica Scandinavica 1987; 58: 239-240