What is the recommended management for a displaced distal phalanx tuft fracture?

Treatment of Displaced Distal Phalanx Tuft Fracture

Most displaced distal phalanx tuft fractures can be managed conservatively with closed reduction and immobilization, but surgical exploration is mandatory when clinical signs suggest nail bed laceration or soft-tissue interposition.

Initial Assessment

When evaluating a displaced distal phalanx tuft fracture, immediately assess for the following clinical features that indicate potential nail bed injury 1:

• Subungual hematoma
• Subluxation or avulsion of the proximal nail plate
• Bleeding from underneath the nail plate
• Skin laceration proximal to the eponychial fold
• Eponychial fold laceration

If any of these features are present, the injury should be treated as an open fracture requiring surgical exploration 1.

Treatment Algorithm

For Fractures WITHOUT Clinical Signs of Nail Bed Injury

• Perform closed reduction with traction and manipulation 2
• Immobilize with splinting for 3-6 weeks 3
• Obtain radiographs at approximately 3 weeks and at immobilization removal to confirm healing 3
• Initiate active finger motion exercises immediately to prevent stiffness 3

For Fractures WITH Clinical Signs of Nail Bed Injury (Most Common Scenario)

Surgical exploration is indicated because 82% of these cases have confirmed nail bed laceration and 47% have soft-tissue interposition at the fracture site 1.

The surgical approach includes 4, 2:

1. Thorough wound irrigation and debridement
2. Fracture reduction through manipulation and traction
3. Nail bed repair if laceration is identified
4. Anatomical replacement of the nail plate to serve as a splint
5. Stabilization using one of these techniques:
   • Vertical figure-of-eight tension band suture through the nail plate (preferred for simplicity and effectiveness) 4, 2
   • Percutaneous K-wire fixation if additional stability is needed 1
   • Hypodermic needle pinning when K-wires are unavailable 5

The vertical figure-of-eight suture technique is particularly advantageous because it simultaneously secures the nail plate, maintains fracture reduction, and does not require formal internal fixation of bone fragments 4, 2.

Post-Treatment Management

• Antibiotic prophylaxis is essential when treating these as open fractures 6
• Immobilization duration: typically 3-6 weeks 3
• Immediate finger motion exercises for adjacent joints to prevent stiffness 3
• Follow-up radiographs at 3 weeks and at cast/splint removal 3
• Monitor for complications: infection (occurs in approximately 6-15% of cases), osteomyelitis, malunion, and nail deformity 1, 6

Critical Pitfalls to Avoid

• Do not underestimate these injuries: Distal phalanx fractures with nail disruption are often open fractures requiring surgical treatment, not simple closed injuries 6
• Avoid undertreating Salter-Harris fractures in pediatric patients, as they frequently have occult nail bed lacerations requiring exploration 1
• Watch for over-tensioning when using figure-of-eight sutures, as this can cause vascular compromise requiring immediate revision 4
• Do not delay treatment of open fractures, as this increases infection risk and can lead to osteomyelitis 6