What is the management for a crush injury of the phalanx with a fracture and nail injury?

Management of Crush Injury of the Phalanx with Fracture and Nail Injury

For a crush injury of the phalanx with fracture and nail injury, immediate management should include radiographic assessment, nail removal with meticulous nail bed repair, fracture stabilization if displaced or involving >1/3 of the articular surface, and prophylactic antibiotics given the high risk of infection with open fractures. 1, 2, 3, 4

Initial Assessment and Imaging

• Obtain a minimum 3-view radiographic series (PA, lateral, and oblique) of the affected digit to assess for fracture displacement, articular involvement, and fracture pattern 1
• Look specifically for intra-articular extension, displacement >2mm, and involvement of >1/3 of the articular surface, as these indicate need for operative fixation 1
• Remove any tight-fitting dressings immediately and assess for compartment syndrome using the "6 Ps": pain, paresthesia, paresis, pain with passive stretch, pink color, and pulselessness 2, 5

Immediate Wound and Systemic Management

• Begin fluid resuscitation if significant crush mechanism with 0.9% normal saline at 1000 ml/h, tapering by at least 50% after 2 hours to prevent crush syndrome and myoglobinuric acute kidney injury 2, 5
• Avoid potassium-containing fluids (Lactated Ringer's, Hartmann's solution, Plasmalyte A) as potassium levels may spike markedly even with intact renal function following reperfusion 2, 5
• Thoroughly irrigate the wound with large volumes of warm or room temperature potable water until no foreign matter remains 2
• Apply cold therapy (ice with water barrier) for 20-minute intervals to reduce pain and swelling 2, 5

Nail and Nail Bed Management

The critical decision point is whether to remove the nail:

• Remove the nail in all cases with visible nail bed laceration, nail avulsion (partial or complete), or subungual hematoma involving >50% of the nail bed 6, 3, 4
• Blunt trauma frequently causes more extensive nail bed injury than initially apparent, making nail removal essential for adequate assessment 6
• Perform meticulous nail bed repair with fine absorbable sutures (6-0 or 7-0) to prevent secondary deformities including split nail, hook nail, and nonadherence 3, 4
• Replace the nail (or nail substitute) into the nail fold after repair to maintain the eponychial fold space and prevent adhesions 4

Common pitfall: Underestimating the extent of nail bed injury leads to inadequate treatment and poor cosmetic/functional outcomes requiring secondary reconstruction with unpredictable results 6, 4

Fracture Management

Fracture treatment depends on specific characteristics:

• Non-displaced or minimally displaced fractures (<2mm): Splint immobilization for 3-4 weeks 1
• Displaced fractures, intra-articular fractures with >2mm step-off, or involvement of >1/3 of articular surface: Operative fixation required to prevent long-term osteoarthritis 1
• Open physeal fractures (Seymour fractures in children): These are frequently missed and require urgent operative treatment; suture-only stabilization is effective and avoids pin-related complications 7
• For fractures with associated nail bed injury, the fracture is by definition open and requires antibiotic prophylaxis 3

Antibiotic Management

• Administer prophylactic antibiotics for all crush injuries with fracture and nail bed involvement as these represent open fractures 3
• Predictors for antibiotic need include crush mechanism, fracture of distal phalanx, and road traffic accidents 3
• Continue antibiotics for 24-48 hours or until wound shows no signs of infection 3

Monitoring and Follow-up

• Watch for dark urine (myoglobinuria), decreased urine output, and signs of kidney dysfunction if significant crush mechanism 2, 5
• Monitor for infection signs: increasing pain, redness, warmth, swelling, or purulent drainage 2
• Predictors of complications include stellate lacerations, severe crush patterns, and presence of distal phalanx fracture 3, 4
• Poorer cosmetic outcomes occur with fold injuries, crush injuries, and avulsive patterns 4

Specific Complications to Anticipate

Expected complication rates from nail bed injuries with fracture include:

• Fingertip sensitivity: 5.3% 3
• Split nail deformity: 5.3% 3
• Infection: 3.9% 3
• Nail nonadherence: 2% 3
• Hook nail deformity: 1% 3

Critical timing consideration: Delayed or inadequate initial treatment substantially increases the risk of these complications and may necessitate secondary reconstruction with unpredictable results 6, 4

When to Refer for Specialist Management

• Complex intra-articular fractures requiring operative fixation 1
• Stellate or severely crushed nail bed injuries 3, 4
• Any concern for compartment syndrome 2, 5
• Missed injuries presenting >48 hours after trauma 7