Tuft fractures & Nail bed injury

Clinical Pearl: Tuft fractures and nail bed injuries often occur together and are thusly presented here together.

Anatomy

Illustration by Dr. Lisa Bryski

A tuft fracture is a fracture of the fine cancelous bone at the distal tip of the distal phalanx.¹

The nail plate or what most people simply call the "nail" is the final part of the activity of 4 epithelia that grow and differentiate in a specific manner, the nail matrix. The nail plate is firmly attached to the nail bed. Injury to the nail bed/matrix can result in future abnormal appearance of the nail.²

Classic Presentation

The tuft fracture is often associated with nail bed or matrix injury. Both tuft fractures and nail bed injuries are usually a result of direct blow, crush, and/or laceration. There are a variety of activities or incidents associated with this type of injury. Industrial accidents, traffic accidents, doors and sports are just a few examples. The patient will present with pain, swelling and possibly a visible laceration to the distal phalanx. Often separation of the nail plate from the nail bed occurs. This manifests as blood under the nail plate (subungual hematoma).

Diagnosis

The diagnosis is based on clinical exam and x-ray. Clinical exam will reveal tenderness, edema, possibly laceration and subungual hematoma. A subungual hematoma should make the practitioner suspicious for a nail bed laceration. Be sure to examine the germinal matrix for any injury.

If there is a fracture or the nail appears elevated or displaced or subungal hematoma is greater then 50% of the nail surface area the nail may need to be removed. Removal allows diagnosis of clinically significant nail bed injury/lacerations.³

Clinical Tip: The diagnosis of open fracture should be made in tuft fractures that are associated with nail bed lacerations.

Management

Tuft Fracture

Controversy exists among hand surgeons on splinting tuft fractures. You don't actually have to splint them and splinting is really for their comfort and reminder that they have an injury. The fibrous septa of the soft tissue envelope keep the tuft fracture well reduced and make it impossible for the fragments to migrate, which splint the fracture pieces itself.

If you are going to splint it, then make sure to extend the splint past the tip of the distal phalanx to protect it from injury for 2-4 weeks.

Note, that prolonged immobilization (>4 weeks) may lead to excessive stiffness and functional loss.

Do not reduce if comminuted. Compression around the tip can help with fragment approximation and symptom control. Splint for 2-4 weeks as above.⁴

Tip: Tuft fractures are different than midshaft distal phalanx fractures, which will require pins if displaced enough.

Nail Bed Injury

Typically, if the surface area of a subungual hematoma is less than 50%, the injury can be managed conservatively. The pressure associated with smaller hematomas can still be painful and may benefit from decompression. Nail trephination (creating a small hole in the nail to decompress) can be performed in acute (<48hrs) hematomas. The presence of a fracture is not a contraindication for trephination.

As mentioned above, if there is a fracture and the nail is elevated/displaced or there is a larger hematoma the nail may need to be removed to look for clinically significant nail bed injury/laceration that will require repair. If a laceration is found and it is associated with a fracture, the patient will require antibiotics for "open fracture" and splinting of the fracture. Some experts feel trephination is sufficient treatment for these injuries as the nail acts as a natural splint and dressing.⁵

Tip: Splinting the nail should be done especially for lacerations involving the germinal matrix.

Illustration by Dr. Jessica Winter

Nail bed repair

Place digital tourniquet
Remove disrupted nail to expose the nail bed
Gently irrigate the area
Carefully repair the nail bed which approximate lacerated edges with chromic or other absorbable suture
Protect the nailbed by splinting with the original nail or using a nonadherent gauze or sterile foil from suture packet (shown in the image on the left)
Apply a protective dressing and splint the finger
Remove the tourniquet

Tip: Place a digital tourniquet – can be a penrose drain secured with a hemostat or a finger cut out from a glove one size smaller than the patient would wear

Discharge Instructions

Remind the patient that the sutured nail is going to fall off within 1-3 weeks, and a new nail will require 3-12 months to grow in.

References

Miller, M. D., Hart, J., & MacKnight, J. M. (2019). Essential Orthopaedics E-Book. Elsevier Health Sciences.
Piraccini, B. M. (2014). Nail disorders: a practical guide to diagnosis and management. Springer.
Bharathi, R. R., & Bajantri, B. (2011). Nail bed injuries and deformities of nail. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India, 44(2), 197.
Chaffin TH. Phalangeal fractures. In: Emergency and Primary Care of the Hand, Hart RG, Uehara DT, Wagner MJ (Eds), American College of Emergency Physcians, Dallas 2001. p.111.
Lee DH, Mignemi ME, Crosby SN. Fingertip injuries: an update on management. J Am Acad Orthop Surg. 2013;21(12):756.

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