Distal Phalangeal Fractures

Kevin D. Plancher

History and Clinical Presentation

A 35 year old carpenter was on the job using a table saw. He forgot to engage the safety and cut the tip of his finger. He presents to the emergency room with exposed bone at the tip of his finger after a transverse cut to his fingertip.

Physical Examination

There is no soft tissue covering the end of the bone. Approximately 40% of the nail and nail matrix are present.

Diagnostic Studies

Anteroposterior (AP), lateral, and oblique radiographs of the injured digit were obtained. The finger was assessed for foreign objects, joint dislocation, subluxation, and fractures.

Differential Diagnosis

Distal phalanx fracture

Vascular injury

Nerve injury

Mallet fracture

Distal phalanx (P3) dislocations

PEARLS

• Expect patients 50% of the time to have cold intolerance, hypersensitivity, and paresthesias.
  
• Sew these flaps with chromic or catgut sutures. Suture to the nail should be absorbable to avoid painful removal in the office.

PITFALLS

• Attention to detail in lifting the V-Y flap in the subcutaneous tissue will provide survival of the tissues.
  
• Adequate incision and drainage with antibiotics will avoid infection in most cases.

Diagnosis

Open Distal Phalanx Fracture with Soft Tissue Loss

The type of injury, the functional goal, and possible complications often determine the treatment of fingertip injuries. Factors to consider include finger sensitivity, a nontender finger, maximum length, nail appearance, normal joint movement, and cosmesis. On initial diagnosis, the viability of the tissues should be assessed to determine which tissue is unlikely to survive. It must also be determined what can be sacrificed and what must be preserved to maintain function.

Transverse amputations are the easiest to repair. Treatment is determined by the coverage of the bone. The amount of nail following injury is also important in determining treatment. Depending on the level of amputation, blood vessel and nerve status must also be determined. In oblique dorsal amputations, if the nail is only partially injured, an attempt must be made to preserve it. The condition of the nail matrix is also important. Oblique palmar amputations are difficult to treat. Thenar flaps are an option. The goal of treatment in a palmar amputation is to provide a reconstructed pulp, which is sensitive and well cushioned.