MANUAL MINORS
Distal phalanx fractures are common finger injuries, often caused by crushing, direct blows, or trauma to the fingertip. This type of fracture can involve the nail bed and compromise both the function and aesthetics of the finger.
Distal fractures can be classified as simple, comminuted (when the bone is shattered into several pieces), or open fractures, and are sometimes associated with nail or soft tissue injuries.
Diagnosis
The diagnosis of a distal phalanx fracture is made through patient history and physical examination of the affected finger. Patients typically present with intense pain, swelling, subungual haematoma, tenderness at the fingertip, and in some cases, visible deformity. It is important to assess finger mobility and check if the injury involves the nail bed or extensor tendon.
The diagnosis is confirmed through X-rays of the hand in multiple views (anteroposterior, lateral, and oblique), which reveal the fracture pattern, displacement, and any bone fragments. In complex fractures or those involving significant nail bed damage, ultrasound or CT scans may provide further details.
Differential Diagnosis
Condition | Main Clinical Characteristics | Key Differentiation |
|---|---|---|
Contusion or subungual haematoma | Pain and haematoma under the nail without visible fracture | Normal X-rays, no fracture evidence |
Nail bed injury | Damage to the nail bed tissue without bone fracture | No radiographic evidence of fracture |
Nail avulsion | Nail detachment with or without underlying fracture | Nail may be detached, but fracture is not always present |
Middle phalanx fracture | Pain, swelling, and deformity in the middle finger segment | Fracture located in the middle phalanx, not distal |
Extensor tendon rupture | Inability to extend the distal phalanx (mallet finger) | Typically no bone fracture, clinically evaluated |
Emergency Management
Initial management of a distal phalanx fracture includes immobilising the affected finger to prevent further displacement of bone fragments and reduce pain. If a subungual haematoma is causing significant pain, trephination (drainage) can be performed to relieve pressure.
For open fractures or nail bed injuries, thorough cleaning with sterile saline is necessary to prevent infection. Antibiotic prophylaxis and tetanus vaccination may be required, especially in cases of open wounds.
A careful assessment of the nail bed and extensor tendon should be conducted to detect any associated injuries that may require surgical intervention.
Definitive Treatment
Definitive treatment depends on the type of fracture:
Non-displaced fractures: Managed with immobilisation using a fingertip splint (stack splint) that keeps the distal phalanx in extension for 3-6 weeks. This conservative approach is sufficient for simple, non-displaced fractures.
Displaced or comminuted fractures: These may require closed reduction to realign bone fragments. If the fracture is unstable, fixation with Kirschner wires or screws may be necessary to ensure stability.
Open fractures or fractures with significant soft tissue injury: Surgical treatment includes nail bed repair, debridement of damaged tissue, and, if needed, closure with skin grafts.
Nail bed injuries: If the fracture affects the nail bed and is associated with nail avulsion, the damaged nail may be removed, and the nail bed repaired with fine sutures. In some cases, the nail or a substitute can be used as a protective splint for the nail bed during healing.
Rehabilitation and Follow-up
After treatment, follow-up is crucial to ensure proper bone healing. Rehabilitation includes early mobilisation of the finger once stability is achieved to prevent stiffness and adhesions. In more severe fractures or those involving tendon injury, physical therapy is essential to restore finger function.
Full recovery may take several weeks, and complications such as malunion (healing in the wrong position), joint stiffness, or nail growth deformities may occur in some cases.
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