How to manage a 270-degree partial avulsion of the distal phalanx of the thumb with exposed bone?

Management of Right Thumb Partial Avulsion of the Distal Phalanx

Immediate surgical repair is required for a 270-degree partial avulsion of the distal phalanx of the thumb with nail separation from the nail bed and exposed bone.

Initial Assessment and Stabilization

• Assess for signs of vascular compromise (blue, purple, or pale appearance of the digit) which would require immediate emergency care 1
• Evaluate neurovascular status by checking capillary refill, sensation, and motor function
• Cover the exposed bone and wound with clean, non-adherent dressings to prevent contamination and infection 2
• Elevate the hand above heart level to minimize swelling
• Apply gentle splinting in the position found without attempting to reduce the avulsion unless there is vascular compromise 1

Wound Management

For the Exposed Bone

• Clean the wound gently to remove visible debris
• Irrigate with sterile saline solution
• Apply a non-adherent dressing to protect the exposed bone 2

For the Separated Nail

• Do not attempt to remove the nail if it's partially attached
• If completely avulsed, the nail can be cleaned and potentially used as a biological dressing
• Avoid placing the nail back into the nail fold if there is significant contamination

Surgical Intervention

Indications for Immediate Surgery

• Exposed bone with nail bed separation requires urgent surgical exploration and repair
• The 270-degree avulsion pattern indicates significant tissue damage requiring specialized surgical management

Surgical Approach

1. Thorough wound debridement and irrigation
2. Anatomical reduction of the avulsed tissue
3. Repair of the nail bed using fine absorbable sutures (6-0 or 7-0)
4. Stabilization of the distal phalanx if fractured
   • For stable fractures: Splinting may be sufficient
   • For unstable fractures: K-wire fixation or small screws (1.5-2.0 mm) may be necessary 3, 4
5. Replacement of the nail plate as a biological dressing to prevent adhesions between the nail fold and nail bed

Post-Surgical Management

• Maintain elevation of the hand to reduce swelling
• Administer appropriate analgesics for pain control
• Consider prophylactic antibiotics if there is significant contamination
• Apply a protective splint to immobilize the thumb while allowing motion of uninvolved digits 1
• Schedule follow-up within 7-10 days for wound assessment and dressing change

Potential Complications

• Infection (monitor for increasing pain, redness, swelling, or purulent drainage)
• Nail deformity (common after significant nail bed injuries)
• Joint stiffness (can be minimized with appropriate rehabilitation)
• Sensory disturbances (may occur due to digital nerve injury)
• Delayed healing or tissue necrosis (especially with vascular compromise)

Rehabilitation

• Begin gentle range of motion exercises for uninvolved digits immediately to prevent stiffness 1
• Once healing begins (typically 10-14 days), initiate gentle active motion of the injured thumb
• Progress to strengthening exercises as healing permits
• Monitor for development of joint stiffness or tendon adhesions

Follow-up Care

• Regular wound checks to assess healing
• Radiographic evaluation to ensure proper alignment if fracture is present
• Monitor for nail regrowth and potential deformities
• Adjust rehabilitation protocol based on healing progress

This management approach addresses both the soft tissue injury and potential bony involvement, with the goal of restoring function and appearance while minimizing complications.