Fingertip (tuft) fractures occur in the distal phalanx. The usual mechanism is a crush injury (eg, in a door jamb).
(See also Overview of Fractures.)
Fingertip fractures are common. They range from simple transverse fractures to complex comminution of the tuft (the flat, wide area at the tip of the distal phalanges). They are often associated with a nail bed laceration, although the nail itself is frequently intact.
Symptoms and Signs of Fingertip Fractures
The fingertip is swollen and tender. A fracture with significant soft-tissue injury may cause hyperesthesia, which frequently persists long after the fracture heals.
Usually, blood becomes trapped between the nail plate and nail bed (subungual hematoma), causing a bluish black discoloration under all or part of the nail, which may be elevated. Subungual hematoma commonly occurs when the nail bed is lacerated.
DR P. MARAZZI/SCIENCE PHOTO LIBRARY
Marked disruption of the nail bed can result in a permanently deformed nail.
Diagnosis of Fingertip Fractures
X-rays
Diagnosis of a fingertip fracture is based on x-rays, which include anteroposterior, oblique, and lateral views. For the lateral view, the affected digit is separated from the others.
Treatment of Fingertip Fractures
Protective covering (eg, finger splint) for 2 weeks
For a large or painful subungual hematoma, nail trephination
Most fingertip fractures are treated symptomatically with a protective covering (eg, commercially available aluminum and foam splint material) wrapped around the fingertip, often for 2 weeks. Rarely, fractures are displaced enough to require surgical repair.
Persistent hyperesthesia may resolve when treated with desensitization therapy.
Subungual hematomas can be drained to relieve pain by puncturing the nail (trephination), usually with an electrocautery device (unless nail polish is present) or an 18-gauge needle in a rotatory, drilling motion; with either method, downward pressure should stop as soon as resistance abates (indicating nail puncture). If trephination is done gently and rapidly, anesthesia is often unnecessary. Otherwise, a digital nerve block (injection of a local anesthetic into the base of the finger) may be used.
Nail bed injury
The nail bed should be repaired with sutures (requiring nail removal) if the nail bed is significantly injured, as long as the wound is not infected and < 24 hours old. Repair is not necessary if the laceration is small and held in place by intact nail folds.
Previously, nail removal was routinely recommended in patients with a crushed fingertip (with or without an underlying fracture) to evaluate the degree of nail bed injury and determine whether repair was required. However, the nail does not need to be removed if there is no significant injury or deformity to the nail itself. In such cases, nail bed laceration, if present, is likely to heal well on its own when a splint is applied; trephination is done as needed to relieve pain caused by a subungual hematoma.
If the nail appears severely injured or deformed, the nail should be removed, and the nail bed repaired with thin, absorbable sutures (eg, 6-0 or 7-0 polyglactin). Then the fingertip is wrapped in nonadherent dressing (eg, petrolatum-impregnated bacteriostatic gauze); the wound should be checked within 24 hours to make sure the nail bed does not adhere painfully to the dressing. Evidence suggests that although the injury is technically an open fracture, antibiotics are not needed after nail bed repair in patients with a tuft fracture.
Key Points
When a fingertip is fractured, the nail bed is often lacerated, causing a subungual hematoma, even when the nail is intact.
Take anteroposterior, oblique, and lateral x-rays; for the lateral view, separate the affected digit from the others.
For most fingertip fractures, wrap the fingertip with a protective covering; it is often needed for 2 weeks.
Treat subungual hematomas by puncturing the nail and draining the blood.
Repair significant lacerations in the nail bed with sutures; if the nail appears severely injured or deformed, remove the nail before repairing it, then wrap the fingertip in nonadherent dressing.
