The distal phalanx physis in the skeletally immature patient represents a potential fault line that can fail in the setting of crush or force loading injuries. Given the radiolucent nature of the physis, radiographic findings of physeal fractures can be subtle. The clinician must therefore have a high index of suspicion for this particular fracture pattern when evaluating the pediatric patient with a fingertip injury (Abzug and Kozin 2013; Krusche-Mandl et al. 2013). Clinically, the patient will often present with a partial avulsion of the proximal nail plate through the eponychial fold. The digit may have a “mallet” appearance. Radiographically, the physis will look wide compared to physes of adjacent, uninjured digits, and there may be displacement of the distal phalanx diaphysis in the dorsopalmar plane (Fig. 1a–d).

When the fracture is displaced, it often tears the proximal nail bed and therefore becomes exposed to the environment. It should thus be considered an open fracture. The nail bed can become interposed between the fracture fragments and prevent reduction. Failure to recognize the injury pattern and reduce the fracture in a timely manner can result in permanent nail deformity, permanent growth disturbance, and osteomyelitis. Removal of the avulsed nail plate will immediately reveal the associated nail bed injury. If the nail bed is interposed between the fracture fragments, it should be withdrawn. The fracture can then be reduced and stabilized with a smooth Kirschner wire. The nail bed laceration should then be repaired.

Many of these procedures can be done in the emergency room setting under local anesthesia with IV sedation, especially in older children. Lidocaine with epinephrine (1 % Lidocaine with epinephrine 1:100,000) has been proven safe at the digital level and may preclude the need for a digital tourniquet (Lalonde 2011; Lalonde and Martin 2013). The patient is placed supine with the injured extremity on a hand table. After a sensory examination has been performed in age-appropriate children, the digit is anesthetized. If epinephrine has not been used, a finger tourniquet should be applied to the base of the digit to provide a bloodless operative field. The nail plate can be removed by passing a Freer Elevator directly under the volar surface of the nail. Care should be taken to angle the elevator toward the nail plate and not toward the nail bed – this will minimize iatrogenic injury to the nail bed. The lateral nail edges should be freed from the lateral nail folds also with the elevator. Once the nail has been mobilized from its attachments to the nail bed and lateral nail fold s, a small clamp should be attached to the lateral aspect of the nail plate and then turned multiple times like “twisting spaghetti on a fork.” This maneuver will allow the nail to roll out from under the dorsal nail fold. The underlying nail bed should now be visible (Fig. 2a). Any gross contamination, bone devoid of an adequate soft tissue envelope, or clearly necrotic tissue should be debrided.