Most fractures of the distal phalanx can be treated nonoperatively.
Nonoperative treatment is based on immobilization of the DIP joint in
extension, leaving the PIP joint free.
Fractures of the distal phalanx are often the result of direct impact, or
crush injuries. Most frequently, there is a comminuted tuft fracture.
Nail bed injuries may need repair and reduction of the nail plate into the
Transverse fractures of the proximal half of the distal phalanx are not
well-suited to nonoperative treatment when there is no direct contact between
the fragments. These fractures are often unstable and, in open fractures, the
nail bed is often folded into the fracture. In these cases, open reduction and
internal fixation are indicated.
Closed crush injuries are often accompanied by a tense subungual hematoma,
which can be exceedingly painful, due to the pressure within the closed
The hematoma can easily be released by puncturing the nail with a red-hot
needle, or paperclip end.
If no further treatment is indicated, apply a simple splint and cool the
finger with the judicious use of an ice pack.
Dorsal splint versus palmar splint
Using a dorsal splint has the advantage of leaving the patient with the
ability to pinch while the digit is immobilized.
However, proponents of palmar splintage argue that the palmar aspect is
better cushioned than the dorsal and, thereby, can tolerate the splint
Contoured custom thermoplastic splint
The advantage of a custom thermoplastic splint is that it is adapted better
to the shape of the finger, and easier to change.
Pitfall: immobilization of the PIP joint
Do not immobilize the PIP joint.
It is advisable precisely to repair the nail bed, or the germinal matrix,
lest permanent deformity of nail growth occur.
Such procedures are difficult, without the help of magnifying loupes. In
many cases, an operating microscope is an even better choice, if available.
Separate fine absorbable sutures should be used.
In simple transverse, or oblique, lacerations of the nail bed, a running
suture may be used.
Pitfall: Eversion or inversion of nail bed edges
Be careful to suture the edges of the nail bed, avoiding eversion or
inversion, otherwise, permanent deformity of nail growth can result.
There are 4 main reasons for nail reinsertion:
- to prevent scarring between the eponychium and the germinal matrix
- to stabilize the fracture
- the nail acts a biological barrier and protection
- it acts as a template for the growth of a new nail.
Insert a needle with a 5-0 nonresorbable nylon suture from the dorsal aspect
into the sinus, exiting the sinus distally to the eponychium.
Pass the needle through the proximal edge of the nail plate.
Then pass the needle back through the nail plate and the sinus of the nail, so
that it exits level with the first pass of the suture, separated from it by
approximately 5 mm.
Draw the nail plate back into the sinus by gentle traction on both ends of
Tie the suture over a cotton, or foam, ball to avoid skin pressure injury.
After reinsertion and proximal fixation, the nail has a tendency to tilt
To prevent this, use a small suture at the nail’s distal tip to secure it to
the nail bed.