What is the treatment for a fracture of the distal phalanx with nail damage?

Treatment of Distal Phalanx Fracture with Nail Damage

For distal phalanx fractures with nail damage, surgical exploration is strongly recommended because nail bed lacerations and soft-tissue interposition are present in 82% and 47% of cases respectively, requiring open reduction with nail bed repair. 1

Initial Assessment

Clinical Examination

• Any of the following clinical findings indicate likely nail bed laceration requiring surgical exploration: 1
  • Subungual hematoma
  • Subluxation of the proximal nail plate
  • Skin laceration proximal to the eponychial fold
  • Bleeding from underneath the nail plate
  • Eponychial fold laceration
  • Nail plate avulsion

Imaging Requirements

• Obtain standard 3-view radiographs (PA, lateral, and oblique views) to evaluate fracture pattern, displacement, and articular involvement 2, 3
• An internally rotated oblique projection in addition to standard externally rotated oblique increases diagnostic yield 3

Treatment Algorithm

Surgical Indications (Most Cases with Nail Damage)

Proceed with surgical exploration and treatment when: 1

• Any clinical feature of nail bed laceration is present (as listed above)
• Fracture displacement >3mm 2, 3
• Articular involvement >1/3 of joint surface 2, 3
• Interfragmentary gap >3mm 2, 3
• Joint instability or incongruity 3

Surgical Technique

• Perform open reduction with nail bed repair and consider the following stabilization options: 1

  • Open reduction with splinting alone (for stable fractures after soft tissue repair)
  • Open reduction with percutaneous pinning (for unstable fractures)
  • Suture-only stabilization is a reliable alternative to pin fixation, particularly in pediatric physeal fractures 4

• At surgical exploration, expect to find: 1

  • Nail bed laceration in 82% of cases
  • Soft-tissue interposition in 47% of cases requiring removal for proper reduction

Conservative Management (Rare in Nail-Damaged Fractures)

• Only consider non-operative treatment if ALL of the following are met: 2, 5

  • No clinical features of nail bed laceration
  • Minimal displacement (<3mm)
  • No articular involvement or <1/3 articular surface
  • Stable fracture pattern

• If conservative management is appropriate, use rigid immobilization with a splint for 3-6 weeks 2

• Immobilize only the DIP joint while allowing PIP joint motion 3

Post-Treatment Management

Early Motion Protocol

• Begin active finger motion exercises immediately for non-immobilized joints to prevent stiffness, which is the most functionally disabling complication 2, 3
• Finger motion does not adversely affect adequately stabilized fractures 2

Follow-up Schedule

• Radiographic follow-up at approximately 3 weeks post-treatment 2, 3
• Additional imaging at time of immobilization removal to confirm healing 3

Monitoring for Complications

• Watch for infectious complications, which occur in approximately 8-15% of cases 1, 3
• Unremitting pain warrants immediate reevaluation 2
• Monitor for joint stiffness, nail deformity, and physeal arrest (in pediatric cases) 4, 1

Critical Pitfalls to Avoid

• The most common error is undertreatment—these injuries are frequently missed or inadequately treated by initial providers 4, 1
• Never treat distal phalanx fractures with clinical signs of nail bed injury conservatively without surgical exploration, as this leads to poor outcomes including infection, chronic pain, and nail deformity 1
• Failure to encourage early motion of non-immobilized joints leads to significant stiffness that is difficult to treat after healing 2
• Overlooking displacement or articular involvement results in poor functional outcomes 2