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Salter-Harris Fractures of the Distal Phalanx: is it Time to Define Optimal Surgical Treatment?
Waleed Gibreel, MBBS; Ali Charafeddine, MD; Karim Bakri, MBBS
Mayo Clinic, Department of Plastic Surgery, Rochester, MN

Introduction: Salter-Harris (SH) fractures of the distal phalanx with or without evidence of nail bed laceration (NBL) are frequently undertreated. We sought to review our experience and propose a treatment algorithm.

Material and Methods: A retrospective review of patients with SH fractures of the DP treated between 2004 and 2016.

Results: Seventy patients (74% male) were treated for 72 SH fractures at a meanąSD age of 11.3ą3.7 years. Median follow-up was 6 weeks [IQR 4-12.6]. The right hand was involved in 43 fractures. The thumb was the most commonly involved (n=21), followed by long (n=18), ring (n=17), small (n=9), and index (n=7). Sport-related injuries accounted for 39 (54%) fractures. SH 2 was the most common (n=50) followed by SH 3 (n=12) and SH 1 (n=10). Eighty percent presented within 24 hours of injury. Forty-Two (58%) fractures had at least one clinical finding suggestive of NBL (CFSNBL). CFSNBL were subungual hematoma (n=16), subluxation of proximal nail plate (n=13), laceration proximal to the eponychial fold (n=12), oozing of blood from underneath the nail plate (n=4), eponychial fold laceration (n=3), and near total/total nail plate avulsion (n=2). Among 42 fractures with CFSNBL, surgical exploration was undertaken in 38 fractures. At exploration, NBL was found in 31 (82%) fractures and soft tissue interposition in 18 (47%) (Table1). Fractures without CFSNBL (n=30) were treated with closed reduction and splinting (CS) (n=24) and closed reduction and percutaneous pinning (PP) (n=6). Fractures with CFSNBL (n=42) were treated with open reduction (OR) and splinting (n=25), OR and PP (n=13), CS (n=4). Excellent results were obtained with few unfavorable outcomes (nail plate deformity in 5, premature physeal closure in 5, abnormal DIPJ ROM in 5, and non-union in 1). Infectious complications occurred in 6 patients (Table2)

Conclusions: The high rate of NBL and soft tissue interposition in fractures with CFSNBL mandates surgical exploration and repair of the nailbed. Excellent outcomes could be achieved via early recognition and initiation of clinical finding-based treatment algorithm. (Figure1)

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