Ortho Hors D'oeuvres (Answer):
To review, the patient is a 14 year-old boy with 4th finger pain after crush injury with exposed nail on exam.
Questions and Answers:
1) Why is an x-ray recommended in a patient with this injury pattern?
An x-ray is recommended for this type of injury pattern to assess for possible osseous injuries in order to differentiate the management required. Distal phalanx fractures are common and account for over half of all hand fractures. The most common causes of distal phalanx fractures include direct blow or crush injury, such as in this case, or axial loading.
Ensure that x-rays are obtained for anterior-posterior (AP), lateral, and oblique views in order to assess the type of fracture sustained, if present. If there is a fracture present, the management of the injury will be different than a soft tissue, finger nail or matrix, or isolated nail bed injury.
2) What type of injury pattern has this patient sustained?
When describing injuries to the digits, it is important to use nomenclature that is clear and specific. Medical providers may or may not include the thumb in their digital numbering, so it is recommended to identify each digit by its name/function.
As you can see in the above film, the patient has sustained a fracture of the distal phalanx of the right ring finger. The fracture is dorsally displaced (displacement typically describes the displacement of the distal fragment to the proximal fragment of a fracture), volarly angulated, and includes a component of the growth plate. This is technically a Salter Harris II fracture of the distal phalanx. Also, given the volar displacement of the fracture, the dorsal aspect of the distal fracture fragment likely protrudes through the epidermal layer of the nail bed, pushing the fingernail up. This injury becomes an open fracture.
3) What is the most appropriate next step in management of this patient’s injury?
Open fractures of the distal phalanx have classically required debridement, thorough washout, and antibiotics. Recent literature, however, is demonstrating that oral or IV antibiotics (keflex 500mg x 5 days or ancef 1gm respectively) may not be necessary in small open fractures of the distal phalanx. The decision made regarding antibiotics should be made in conjunction with the consulting hand surgeon.
The fracture should otherwise be managed with thorough irrigation, closure, and reduction. Splinting should occur over the DIP only and in slight extension. Care should be taken not to splint over the PIP as this can cause recovery delays because of unnecessary involvement of FDS. If there is nailbed involvement, the nail (or nail substitute) should be replaced in the eponychial fold and sutured in place.
Patients who have phalangeal fractures that are displaced, require reduction, or involve the growth plate should have follow up with hand surgery within one week. Patients with non-displaced, closed, or tuft fractures (bony crush injury to the distal tip of the distal phalanx) may be managed with splinting alone for a total of two-four weeks until the fracture is completely healed.
Gaston RG, Chadderdon C. Phalangeal fractures: displaced/nondisplaced. Hand Clinic 2012; 28: 395-401.
Oetgen ME, Dodds SD. Non-operative treatment of common finger injuries. Curr Rev Musculoskelet Med. 2008; 1:97-102.
Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. J Hand Surg. 2003; 28: 388
Wang QC, Johnson BA. “Fingertip Injuries.” Am Family Physician. 2001 May; 63(10): 1961-1966. http://www.aafp.org/afp/2001/0515/p1961.html