How to manage a patient with a subungual hematoma and knee pain?

Management of Subungual Hematoma and Knee Pain

For the subungual hematoma, immediate decompression is recommended to relieve pain and prevent further damage to the nail bed, but postponing the procedure for 7 days with Epsom salt soaks is acceptable if the patient is not in severe pain.

Subungual Hematoma Management

Assessment

• Subungual hematomas typically result from crush injuries or repetitive trauma 1
• Radiographs should be obtained due to high incidence of associated distal phalangeal fractures 2, 3
• Evaluate size of hematoma and presence of pain

Treatment Options

1. Immediate Management:

   • Nail trephination (creating a small hole in the nail) is the first-line treatment to decompress the hematoma 4
   • Can be performed using electrocautery, which provides precise, painless evacuation 3
   • Prompt decompression significantly reduces pain and prevents further damage to nail bed 2

2. Conservative Management (when procedure is postponed):

   • Epsom salt foot soaks at bedtime as prescribed is appropriate for temporary management
   • This helps reduce inflammation and provides comfort while waiting for definitive treatment

3. Definitive Treatment:

   • Complete nail removal with nail bed repair is generally unnecessary, regardless of hematoma size 4
   • For simple subungual hematomas, nail trephination alone is sufficient and avoids complications 4

Follow-up Considerations

• Patients should be warned about potential complications including:
  • Onycholysis (separation of nail from nail bed)
  • Transient or permanent nail deformity
  • Risk of infection 2
• Average time for nail regrowth is approximately 4 months 4
• If the hematoma is associated with a subungual tumor (exostosis or osteochondroma), complete excision with curettage of the base would be necessary 2

Knee Pain Management

Assessment

• Evaluate for:
  • Location and character of pain
  • History of trauma or repetitive use
  • Associated swelling, instability, or mechanical symptoms

Treatment

• Knee brace prescription is appropriate for initial management of left knee pain
• This provides support and stability while allowing for further evaluation at follow-up
• Additional conservative measures to consider:
  • Rest and activity modification
  • Ice application for 15-20 minutes several times daily
  • Elevation when possible
  • Over-the-counter anti-inflammatory medications if not contraindicated

Follow-up Plan

• Re-evaluate knee at next visit (when patient returns for nail procedure)
• Consider imaging if pain persists despite conservative management
• Assess need for physical therapy or specialist referral based on clinical findings

Important Considerations

• While postponing the subungual hematoma treatment is not ideal, it is acceptable if:
  • The patient is not in severe pain
  • There are no signs of infection
  • The hematoma is not causing significant pressure on the nail matrix
• The Epsom salt soaks will help reduce inflammation and provide comfort during the waiting period
• Document clearly the patient's request to postpone the procedure and the interim management plan