Distal phalanx fracture - undisplaced
Some distal phalanx fractures require surgery and some don't.
Fractures affecting the distal phalanx generally result from a crush injury, such as getting your fingertip caught in a door, or dropping a heavy weight on it. These injuries are often associated with injury to the nail bed or the nail, which may require surgery in itself. A subungual haematoma (this term means "a collection of blood under the nail") is a sign of injury to the nail bed.
Often a distal phalanx fracture is a "tuft" fracture, which means that a small fragment or fragments of bone are chipped off the edge of the distal phalanx. These bone injuries do not require wiring or pinning, as they will heal by themselves. The significance of the injury is predominantly that your fingertip will be sore for longer. If you hit your thumb with a hammer you might expect it to be sore for a couple of weeks. If you hit your thumb with a hammer and you break the bone you'll likely find that it's sore to pressure for 6 weeks or more. In this situation, wearing a bulky bandage or a "thimble" type plastic splint can be helpful in preventing you from knocking your distal phalanx while it heals. Tuft fractures don't need to be put in a cast.
Distal phalanx fracture - displaced or unstable
If a distal phalanx fracture is significantly displaced it is likely that surgery will be recommended. Usually such a fracture will also have a break in the nail bed, which places the wound and fracture at risk of infection. In such instances the wound should be thoroughly cleaned and antibiotic treatment started. Surgery is best performed within 48-72 hours.
Surgery to fix the fracture can be done in a variety of ways. In some instances your surgeon may tell you about two different ways, and seek your input on which you think would work best for you. Generally your doctor will recommend one particular type of surgery taking into consideration your injury and factors like your occupation, hand dominance, hand use and preferences. Plates and screws are not commonly used in displaced distal phalanx fractures - they are more commonly treated either with a temporary K-wire or with no metal. However, in some instances the use of small surgical screws is the most appropriate treatment.
In most instances these injuries heal very well. To improve your rate of recovery:
- follow your surgeon's instructions
- don't smoke
- avoid further injury to your fingertip
- keep your finger elevated after the initial injury and after surgery to reduce swelling
- follow your hand therapist's instructions - the instructions will help to reduce swelling, protect your finger, prevent stiffness and improve your range of joint movement
Distal phalanx intra-articular fracture
This most commonly happens with a mallet finger injury, or less commonly when the flexor tendon pulls off a fragment of the bone ("FDP tendon avulsion"). Intra-articular fractures are fractures that involve the joint surface. It is very important that intra-articular fractures are treated properly to reduce the risk of post traumatic osteoarthritis. Generally speaking, if the joint fragments are displaced by more than 1mm or if it involves greater than 1/3 of the joint surface (for a mallet finger injury) it will be recommended that you have surgery, because an irregular joint surface carries a high risk of subsequent arthritis.
What can go wrong?
In most instances surgery is successful in realigning the broken bone and patients go on to have a complete functional recovery. Sometimes the fracture does not heal, in which case further surgery is usually recommended if the finger remains painful. Sometimes the joint surface is broken into multiple small fragments and it is very difficult to repair the joint. If the joint cannot be successfully repaired the subsequent options may include:
- living with a stiff or painful joint
- having a joint fusion (a fused joint is not painful, but it does not move)
- having a joint replacement (although a joint replacement is not commonly done for the distal interphalangeal joint)
- amputation of the finger tip (uncommon)
Don't be alarmed, by this list though. The majority of people who have a distal phalanx fractures make a full recovery and never have to consider these options. Prompt specialist treatment is the best way to get your broken finger healing, so if you have any concerns or questions please contact Melbourne Hand Surgery.
Image credit: hand skeleton image from DrawMD.