What is the initial approach for managing a non-healing distal tuft fracture?

Management of Non-healing Distal Tuft Fractures

For non-healing distal tuft fractures, surgical fixation with open reduction, Kirschner wire fixation, and bone grafting is recommended when conservative management has failed. 1, 2

Initial Assessment and Classification

• Non-healing distal tuft fractures should be evaluated for displacement (>3mm), dorsal tilt (>10°), or intra-articular involvement, as these factors influence treatment decisions 3, 4
• Radiographic evaluation is essential to confirm diagnosis, assess fracture pattern, and determine the extent of non-union 5, 4
• Patients with unremitting pain during follow-up should be thoroughly reevaluated, as this may indicate non-union or other complications 3

Treatment Algorithm

Step 1: Confirm Non-healing Status

• Radiographic follow-up at approximately 3 weeks post-initial treatment to assess healing progress 5, 4
• Additional imaging at the time of immobilization removal to confirm adequate healing or diagnose non-union 5

Step 2: Surgical Management

• Open reduction with Kirschner wire fixation and bone grafting is the recommended approach for established non-union of distal tuft fractures 1, 2
• The surgical principles applied to shaft fractures of middle and proximal phalanges should also be applied to distal phalanx fractures 2

Step 3: Post-surgical Care

• Active finger motion exercises should be performed following surgery to prevent stiffness, which is one of the most functionally disabling adverse effects 3, 5
• Finger motion does not adversely affect adequately stabilized fractures in terms of reduction or healing 5

Potential Complications and Prevention

• Joint stiffness is a significant complication that can be minimized with early appropriate finger exercises 3, 4
• Immobilization-related adverse events occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 5, 4
• Surgical complications may include infection, hardware problems, or continued non-union 6

Special Considerations

• The treating surgeon must weigh the benefits of surgical intervention against potential complications based on patient factors 6
• For elderly patients (>55 years), the evidence does not clearly demonstrate differences between casting and surgical fixation, requiring careful consideration of patient-specific factors 3
• Prevention of complications can be achieved with proper understanding of the mechanism of these complications and appropriate surgical technique 6

Follow-up Protocol

• Regular radiographic evaluation is essential to monitor healing progress 5, 4
• Clinical assessment of pain, function, and range of motion should be performed at follow-up visits 3
• If surgical intervention is performed, monitor for hardware-related complications 6