What is the management for an acute open fracture of the distal phalanx with a laceration extending into the nail?

From the Guidelines

Management of an acute open fracture of the distal phalanx with a laceration extending into the nail requires prompt treatment to prevent infection and optimize healing, with initial management including thorough wound irrigation with normal saline and careful debridement of any devitalized tissue, as recommended by the American Academy of Orthopaedic Surgeons 1. The fracture should be reduced if displaced, and the nail bed meticulously repaired with 6-0 or 7-0 absorbable sutures. If the nail is intact, it can be cleaned and replaced as a biological dressing to protect the nail bed and maintain the nail fold space. Prophylactic antibiotics should be started immediately, typically with a first-generation cephalosporin such as cefazolin 1-2g IV for adults or 25-50 mg/kg for children, followed by oral cephalexin 500mg four times daily for 5-7 days, as suggested by the guidelines for prevention of surgical site infection after major extremity trauma 1. Tetanus prophylaxis should be updated if needed. The finger should be immobilized with an aluminum splint in functional position for 3-4 weeks. Pain management typically includes acetaminophen and NSAIDs, with limited opioids if necessary. Close follow-up within 48-72 hours is essential to assess for signs of infection, and surgery timing should be as soon as reasonable and ideally before 24 hours post injury, as recommended by the American Academy of Orthopaedic Surgeons 1. Key considerations in the management of this injury include:

• Prompt and thorough wound irrigation and debridement
• Appropriate use of prophylactic antibiotics
• Timely surgical intervention
• Immobilization and pain management
• Close follow-up to monitor for signs of infection. The use of local antibiotic strategies as an adjunct to systemic antibiotics may also be beneficial, as suggested by the guidelines 1. Overall, a comprehensive approach that addresses both the fracture and soft tissue injury is essential to reduce the risk of infection and promote proper healing of both the bone and nail complex.

From the Research

Management of Acute Open Fracture of the Distal Phalanx

The management of an acute open fracture of the distal phalanx with a laceration extending into the nail involves several key considerations:

• Debridement and Irrigation: Early debridement and irrigation are crucial in reducing the risk of infection, as demonstrated by studies such as 2, which showed that early antibiotics and debridement independently reduce infection in an open fracture model.
• Antibiotic Prophylaxis: The use of prophylactic antibiotics in the treatment of open fractures of the distal phalanx is a topic of debate. A study by 3 found that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit.
• Stabilization of the Fracture: Stabilization of the fracture is essential to promote healing and prevent complications. A study by 4 demonstrated the use of a Herbert screw in the treatment of an unstable open fracture of the distal phalanx, allowing for early active motion of the distal inter-phalangeal (DIP) joint.
• Surgical Exploration: In cases where there are clinical findings suggestive of nail-bed laceration, surgical exploration is often necessary to assess and treat any underlying injuries. A study by 5 found that among fractures with at least one feature of nail-bed laceration, surgical exploration was undertaken in 38 fractures, and a nail-bed laceration was found in 31 fractures (82 percent).
• Treatment Algorithm: The treatment algorithm for Salter-Harris fractures of the distal phalanx involves a retrospective review of patients treated between 2004 and 2016, as described in 5. The study found that excellent results were obtained, with few unfavorable outcomes, and infectious complications occurred in six patients.

Key Considerations

• Prompt diagnosis and appropriate treatment are necessary to prevent negative sequelae such as osteomyelitis, malunion, nonunion, or premature growth arrest, as highlighted in 6.
• The timing of initial debridement and antibiotic prophylaxis can significantly impact the rate of infection, as demonstrated in 2.