What treatment approach is recommended for a patient with subungual hematoma undergoing toenail removal and complaining of knee pain?

Management of Subungual Hematoma and Knee Pain

For the patient with subungual hematoma, Epsom salt foot baths are appropriate, but the toenail removal should be reconsidered as simple trephination (drainage) is typically sufficient for pain relief with fewer complications and lower cost.

Subungual Hematoma Management

Assessment and Diagnosis

• Confirm the diagnosis is a subungual hematoma (blood collection under the nail) rather than onychomycosis or other nail pathology
• Evaluate the percentage of nail involvement and whether the nail margin is intact
• Check for associated distal phalangeal fractures with radiographs 1

Recommended Treatment Approach

1. First-line treatment: Trephination (nail drainage)

   • Simple decompression through creating a small hole in the nail to release pressure
   • Provides immediate pain relief 2
   • No need for complete nail removal in most cases 3
   • Much lower cost compared to nail removal procedures (approximately 4 times less expensive) 3

2. When to consider nail removal:

   • Only if there is:
     • Evidence of nail bed laceration requiring repair
     • Significant nail disruption or detachment
     • Suspected underlying infection or abscess

3. Post-procedure care:

   • Epsom salt foot baths (as prescribed) are appropriate for:
     • Promoting healing
     • Reducing inflammation
     • Providing comfort
   • Duration: 7 days at bedtime as prescribed is reasonable

Evidence-Based Considerations

• Research shows no notable difference in outcomes between nail removal with bed repair versus simple trephination, regardless of hematoma size 3
• Complete nail removal carries higher risks of:
  • Transient nail abnormalities (depression or hypertrophy)
  • Longer recovery time
  • Higher costs
  • Potential for permanent nail deformity 3

Common Pitfalls to Avoid

• Overtreatment with unnecessary nail removal
• Failure to obtain radiographs to rule out fracture
• Neglecting to warn patients about possible complications:
  • Onycholysis (nail separation)
  • Transient or permanent nail deformity
  • Secondary infection 1

Knee Pain Management

Assessment

• Evaluate for:
  • Mechanism of injury
  • Location and character of pain
  • Associated swelling, instability, or limited range of motion

Recommended Treatment

• Knee brace prescription is appropriate for:
  • Providing stability
  • Reducing pain during movement
  • Promoting proper healing

Additional Recommendations

• Consider adding:
  • NSAIDs for pain and inflammation if not contraindicated
  • Rest, ice, compression, and elevation (RICE protocol)
  • Physical therapy referral if pain persists beyond 2 weeks

Follow-up Recommendations

• Schedule follow-up in 2 weeks to:
  • Assess healing of the nail
  • Re-evaluate knee pain and effectiveness of brace
  • Consider additional interventions if needed

By following this evidence-based approach, you can effectively manage both the subungual hematoma and knee pain while avoiding unnecessary procedures and complications.