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X-Ray features, anatomy and treatment
A man in his 40s presents with finger pain and swelling after a hyperextension injury. The X-ray looks normal at first glance, but there’s more to see.
In this case, we’ll walk through the importance of two views in finger trauma, show how to spot a volar plate injury, and explain why the lateral X-ray is key to making the diagnosis.
A male in his 40s presents with pain and swelling in his index finger following a hyperextension injury. Have a look at the X-Ray below.
PA (left) and lateral (right) views of the index finger
Here is a video explanation of this case: click full screen in the bottom right corner to make it big. If you prefer though I go through this in the text explanation below.
Let’s begin with the frontal X-ray of the index finger.
Annotated image of the PA view of the X-Ray showing the basic anatomy.
In trauma imaging, one view is never enough. A single projection may miss critical findings. Let’s move to the lateral X-ray to get a clearer picture.
On the lateral X-ray:
This location is classic for a volar plate injury.
Lateral view shows a fracture at the base of the middle phalanx.
The volar plate is a fibrocartilaginous structure that stabilizes the PIP joint and prevents hyperextension.
Most commonly at the base of the middle phalanx due to checkrein ligaments reinforcing the proximal phalanx insertion.
The injury may present with a visible avulsion fracture fragment. In severe cases, there can be subluxation or even dislocation of the PIP joint.
The volar plate stablises the proximal interphalangeal joint (PIPJ) and inserts onto the base of the middle phalanx.
Most volar plate injuries are managed conservatively with splinting.
When should we intervene?
Surgical intervention is considered if the fracture involves more than 40% of the joint surface or if it cannot be reduced to less than 30 degrees of flexion.
In hyperextension injuries remember to interrogate the middle phalanx on the lateral view so as to not miss a volar plate injury.
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