What is the appropriate initial management for an uncomplicated tuft fracture of the distal fingertip phalanx?

Management of Uncomplicated Tuft Fractures

For uncomplicated tuft fractures of the distal phalanx, splint the distal interphalangeal joint for 4-6 weeks without formal fracture fixation. 1

Initial Diagnostic Imaging

• Obtain a minimum 3-view radiographic series (posteroanterior, lateral, and oblique) of the affected finger, as 2-view examinations miss a significant proportion of phalangeal fractures 2, 3
• The oblique view is critical for detecting fractures that are occult on standard PA and lateral views 2, 3
• For thumb injuries specifically, a 2-view examination is usually sufficient 3

Treatment Algorithm for Tuft Fractures

Conservative Management (Standard Approach)

• Splint the distal interphalangeal joint in slight flexion for 4-6 weeks for uncomplicated tuft fractures caused by crush injury 1
• Buddy-taping alone is insufficient for distal phalanx fractures; formal DIP joint immobilization is required 1
• No formal fracture fixation (K-wire or other hardware) is needed for simple, non-displaced tuft fractures 4, 1

When to Consider Operative Management

• Articular step-off or gap ≥2 mm requires operative fixation to prevent post-traumatic osteoarthritis 2, 3
• Large fracture fragments involving substantial articular surface may require open reduction and internal fixation 3
• Irreducible tuft fractures with significant displacement of the proximal fragment into the pulp (rare pattern) require open reduction due to entrapment within fibrous septa 5

Critical Pitfalls to Avoid

• Always obtain radiographs before suturing any fingertip crush injury, as occult fractures fundamentally alter management 2
• Failure to obtain 3-view radiographs leads to missed fractures and underestimation of displacement 3
• If the injury involves nail bed disruption with an underlying physeal injury in children (Seymour's fracture), treat as an open fracture with thorough debridement, nail bed repair, and K-wire fixation to prevent infection, growth arrest, and nail dystrophies 6
• Do not assume all tuft fractures are reducible by closed means; some have bony spikes entrapped in pulp requiring open reduction 5

Associated Soft Tissue Management

• When nail plate disruption accompanies the fracture, the nail can be anatomically replaced and secured with vertical figure-of-eight tension band suture without formal fracture fixation, achieving excellent outcomes 4
• Thoroughly clean and debride any open wounds associated with the fracture 6