What is the treatment for a non-healing distal tuft fracture?

Treatment for Non-healing Distal Tuft Fracture

Surgical fixation with Kirschner wire and bone grafting is the recommended treatment for non-healing distal tuft fractures. 1, 2

Assessment and Classification

• Non-healing distal tuft fractures are uncommon but can cause persistent pain and functional limitations 2
• Evaluate for displacement (>3mm), dorsal tilt (>10°), or intra-articular involvement, as these factors influence treatment decisions 3
• Radiographic evaluation should confirm the diagnosis, fracture pattern, and non-union status 3

Treatment Algorithm

For Non-healing Distal Tuft Fractures:

1. Surgical Management (Recommended):

   • Open reduction with Kirschner wire fixation and bone grafting is the treatment of choice for established non-unions 1, 2
   • This approach applies the same principles used for shaft fractures of other phalanges to the distal phalanx 2

2. Special Considerations:

   • Some tuft fractures may have unique fracture patterns with significant displacement that are irreducible by closed means 4
   • This irreducibility may be due to entrapment of bony spikes within fibrous septa of the pulp or overlapping of fracture fragments 4

Post-operative Management

• Active finger motion exercises should be performed following surgical fixation to prevent stiffness, which is one of the most functionally disabling adverse effects 3
• Finger motion does not adversely affect adequately stabilized fractures in terms of reduction or healing 5
• Radiographic follow-up is recommended at approximately 3 weeks post-surgery and at the time of any immobilization removal to confirm adequate healing 3

Potential Complications

• Immobilization-related adverse events occur in approximately 14.7% of cases and may include skin irritation and muscle atrophy 3
• Joint stiffness is a significant potential complication without proper treatment and rehabilitation 3, 6
• For irreducible fractures, failure to recognize the need for surgical intervention may lead to persistent pain and dysfunction 4

Important Clinical Pearls

• While removable splints are appropriate for minimally displaced acute fractures 5, they are insufficient for established non-unions of the distal tuft 1, 2
• The principles of treating shaft fractures in other phalanges should be applied to distal phalanx fractures that have progressed to non-union 2
• Do not confuse management of acute tuft fractures with treatment of established non-unions, as the latter requires more aggressive surgical intervention 1, 2