What is the initial approach to managing a patient with splinter hemorrhage?

Management of Splinter Hemorrhages

The initial approach to managing a patient with splinter hemorrhages should focus on identifying the underlying cause, as splinter hemorrhages are often a sign of an underlying condition rather than a primary condition requiring specific treatment.

Clinical Assessment

History and Physical Examination

• Assess for trauma history (most common cause of splinter hemorrhages) 1
• Evaluate for symptoms of infective endocarditis:
  • Fever
  • Heart murmurs
  • Other vascular phenomena (Janeway lesions, Osler nodes)
• Check for signs of vasculitis or connective tissue disorders
• Review medication history (particularly anticoagulants)
• Document duration, pain, and distribution of splinter hemorrhages

Key Physical Characteristics

• Location: Usually in distal one-third of nails, but can appear in middle or proximal portions 2
• Appearance: Non-blanchable, reddish-brown linear hemorrhages beneath the nails
• Distribution: May affect single or multiple nails
• Associated symptoms: Fresh lesions may be associated with burning sharp pain and tenderness lasting a few days 2

Diagnostic Approach

Laboratory Testing

• Complete blood count
• Erythrocyte sedimentation rate
• Blood cultures (if suspecting infective endocarditis)
• Antiphospholipid antibodies (if multiple splinter hemorrhages with thrombotic events) 3

Imaging

• Echocardiography if suspecting infective endocarditis

Differential Diagnosis

1. Trauma (most common cause) 1
2. Idiopathic (can occur in healthy individuals with spontaneous resolution) 1, 2
3. Infective Endocarditis
   • Splinter hemorrhages have 26% sensitivity and 83% specificity for IE 4
4. Antiphospholipid Syndrome
   • Can present with multiple fingernail subungual splinter hemorrhages concurrent with thrombotic events 3
5. Other Associated Conditions 5:
   • Dermatological diseases (psoriasis, lichen planus)
   • Vasculitis
   • Systemic infections
   • Drug-induced causes

Management Algorithm

1. If traumatic cause is identified:

   • Reassurance
   • Avoid further trauma to affected nails
   • Monitor for resolution (typically occurs within weeks)

2. If idiopathic with no concerning features:

   • Observation and reassurance
   • Document with photographs to monitor progression
   • Follow up in 3 months to confirm resolution 1

3. If suspecting infective endocarditis:

   • Immediate blood cultures
   • Echocardiography
   • Hospitalization if hemodynamically unstable
   • Empiric antibiotics if high clinical suspicion

4. If associated with antiphospholipid syndrome or vasculitis:

   • Refer to rheumatology
   • Consider anticoagulation therapy if thrombotic events present 3

5. If medication-induced:

   • Consider medication adjustment in consultation with prescribing physician
   • Monitor for resolution after medication changes

Important Considerations

• Despite being classically associated with infective endocarditis, splinter hemorrhages are not included in the current Duke diagnostic criteria for IE 4
• Idiopathic splinter hemorrhages often resolve spontaneously within 3 months 1
• Chronic recurrent splinter hemorrhages can occur in healthy individuals for years without underlying disease 2
• Multiple subungual splinter hemorrhages occurring simultaneously with arterial thrombotic events should raise suspicion for antiphospholipid syndrome 3

Pitfalls to Avoid

• Do not assume all splinter hemorrhages indicate serious underlying disease; many cases are traumatic or idiopathic
• Avoid unnecessary extensive workups in patients with isolated splinter hemorrhages and no other concerning symptoms
• Do not dismiss multiple, non-traumatic splinter hemorrhages without appropriate evaluation, especially when accompanied by systemic symptoms