What is the treatment for an open tuft fracture of the distal phalanx?

Treatment of Open Tuft Fracture of the Distal Phalanx

For open tuft fractures of the distal phalanx, the primary treatment should focus on appropriate wound care, antibiotic prophylaxis, and immobilization, as these fractures rarely need specific treatment for the fracture itself beyond management of the surrounding soft tissues. 1

Initial Assessment and Management

• Radiography is essential as the initial imaging, with at least 3 views recommended to properly evaluate the fracture pattern and associated injuries 2
• For distal phalanx fractures, radiographs should assess the degree of displacement, articular involvement, and associated soft tissue injuries 3
• Open fractures require thorough irrigation and debridement to prevent infection 3
• Antibiotic prophylaxis is indicated for all open fractures to reduce infection risk 3

Treatment Algorithm

Conservative Management (Primary Approach)

• Rigid immobilization with a splint for 3-6 weeks is indicated for most tuft fractures, as these rarely require surgical intervention 3, 1
• Active finger motion exercises should be performed following diagnosis to prevent stiffness, which is one of the most functionally disabling adverse effects 2, 3
• Finger motion does not adversely affect adequately stabilized fractures in terms of reduction or healing 2

Surgical Intervention (Limited Indications)

• Surgery should be considered only when there is:
  • Significant displacement (>3mm) 3
  • Involvement of more than one-third of the articular surface 3
  • Palmar displacement of the distal phalanx 3
  • Interfragmentary gap of >3mm 3

Special Considerations for Open Fractures

• Open fractures require more aggressive management due to contamination risk 3
• Thorough wound cleansing and debridement are essential 3
• Nail bed injuries associated with open tuft fractures require repair to prevent nail deformities 4, 5
• Displaced Salter-Harris phalangeal fractures with concomitant nailbed injury require prompt diagnosis and treatment to prevent complications such as osteomyelitis, malunion, nonunion, or premature growth arrest 4

Post-Treatment Management

• A home exercise program is an effective option for patients after fracture immobilization 2
• Instructing the patient to move the fingers regularly through a complete range of motion helps minimize the risk of stiffness complications 2
• Unremitting pain during follow-up warrants reevaluation, as this may indicate complications 2, 3

Complications and Their Management

• Non-union of distal phalanx fractures is rare but can occur, especially in shaft fractures 6, 7
• If non-union develops, surgical intervention with open reduction and Kirschner wire fixation may be necessary 6, 7
• Hand stiffness is one of the most functionally disabling adverse effects and may require additional therapy 2
• Infection risk is higher in open fractures and requires vigilant monitoring 4, 5

Common Pitfalls to Avoid

• Failure to encourage early finger motion can lead to significant stiffness that is difficult to treat after fracture healing 2
• Overlooking displacement or articular involvement can lead to poor functional outcomes 3
• Delayed diagnosis of open physeal fractures can lead to complications including infection, malunion, nonunion, or growth arrest 4, 5
• Underestimating the importance of soft tissue management in open fractures can lead to poor outcomes 1