CHAPTER 111
Fingertip (Tuft) Fractures
Presentation
The patient seeks help after a crushing injury to the fingertip, such as catching it in a closing car door. The finger tip will be swollen and painful, with ecchymosis. There may or may not be a subungual hematoma, open nail bed injury, or fingerpad laceration.
What To Do:
Assess for associated injuries and distal interphalangeal (DIP) joint instability.
Obtain finger radiographs with anteroposterior and lateral views.
If there are open wounds, perform a digital block (see Appendix B), thoroughly cleanse and débride any open wounds, and repair any nail bed lacerations (see Chapter 146).
For open-tuft fractures with clean wounds, prophylactic antibiotic coverage is not indicated. Early aggressive local wound care has been found to be the best prevention against infection in open fingertip fractures. When there is gross contamination with marginally viable tissue, prophylactic antibiotics such as cefazolin (Ancef), 1000 mg IV, followed by cephalexin (Keflex), 500 mg qid PO × 5 days, may be appropriate.
Provide tetanus prophylaxis for open fractures (see Appendix H).
Treat painful subungual hematomas (see Chapter 156).
Apply a sterile, nonadhesive protective dressing to open wounds (see Appendix C), and with or without an open wound, provide an aluminum fingertip splint (Figure 111-1) to prevent further injury and pain.
Figure 111-1 Aluminum fingertip splint.
If necessary, provide oral analgesics and advise the patient to elevate the injury above the heart to minimize swelling.
Ensure follow-up to monitor the patient’s recovery, and in the case of open fracture, to intervene in the event of infection.
What Not To Do:
Do not splint the proximal interphalangeal joint.
Do not prescribe prophylactic antibiotics for clean and uncomplicated open fractures of the distal tuft. Prophylactic antibiotics have been shown to be of no benefit when aggressive irrigation and débridement have been provided.
Do not obtain cultures from acute open-tuft fractures. They have not been shown to be helpful in making therapeutic decisions.
Distal phalanx fractures are the most frequently seen fractures of the hand, with the tuft being the most common site. Fractures at the base of the distal phalanx may lead to chronic pain and degenerative changes in the distal interphalangeal joint if there is significant intra-articular involvement, and require referral to an orthopedic or hand surgeon
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