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A 50-year-old woman presents with a subungual hematoma involving more than 50% of her nail.
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Radiograph of the patient shows a distal phalanx fracture or tuft fracture of the index finger.
A 50-year-old woman presents with a fingertip injury after getting her right index finger caught between a board and a cement block. Radiographs taken in the emergency department 4 days previously show a distal phalanx fracture (tuft fracture) of the index finger. She also has a subungual hematoma involving more than 50% of her nail. She rates her pain as 5 out of 10, which has somewhat improved over the past few days.
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A subungual hematoma, or bleeding under the nail, commonly occurs after crush injuries of the fingertip. The affected nail may become swollen and quite painful.
Treatment of these injuries is controversial, and there are conflicting recommendations. Subungual hematomas involving more than 50% of the nail generally include a nail bed injury. Those with tuft fracture (distal phalanx fracture) have accompanying nail bed injury in 90% of cases. Several authors recommend removing the nail in these cases to repair the nail bed directly.1,2 However, more commonly, the nail is left in place regardless of the size of the subungual hematoma.
Removing the nail can be a traumatic experience for patients and requires a lengthy period of wound care as the nail heals. Leaving the nail intact helps keep the nail bed approximated and is much easier for patients to care for.
Patients with severe pain with a subungual hematoma may require decompression of the hematoma.1,2 Decompression can be achieved by making 2 to 3 small holes in the nail (nail trephination) above the hematoma using electrocautery or a heated paper clip.
Distal phalanx fractures should be treated with a splint to immobilize and protect against contact for 6 weeks. Patients should be advised that these fractures may heal slowly, especially if there is displacement or comminution, and sensitivity over the fingertip for 3 to 4 months is common.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999;24:1166-1170.
- Wang QC, Johnson BA. Fingertip injuries. Am Fam Physician. 2001;63:1961-1966.
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