What is the treatment for a patient with a distal finger fracture and a subungual hematoma causing significant pressure that requires nail bed drainage?

Management of Distal Finger Fracture with Subungual Hematoma

For a patient with a distal finger fracture and subungual hematoma causing significant pressure, immediate nail trephination should be performed to drain the hematoma, followed by appropriate fracture management. This approach addresses both the painful pressure from the hematoma and the underlying fracture.

Subungual Hematoma Management

1. Nail Trephination Procedure:

   • Perform controlled nail trephination to drain the subungual hematoma
   • Methods include:
     • Using an 18-gauge needle after local anesthetic block 1
     • Specialized nail drill that penetrates the nail plate without damaging the nail bed 2
     • Electrocautery device 3

   Note: Avoid using heated paper clips as they may sear the underlying fluid and plug the drainage hole 1

2. Benefits of Prompt Drainage:

   • Immediate pain relief due to pressure reduction 2, 4
   • Prevention of further nail bed damage
   • No need for nail removal with simple subungual hematomas, regardless of size 3

Fracture Management

After addressing the hematoma, manage the distal finger fracture:

1. Assessment:

   • Obtain radiographs to assess fracture pattern and displacement 5
   • Evaluate stability and alignment of the fracture

2. Treatment Options:

   • For stable, non-displaced or minimally displaced fractures:

     • Closed reduction and immobilization with appropriate splinting 5
     • Follow-up radiographs at 10-14 days to evaluate position 5

   • For unstable or significantly displaced fractures:

     • Surgical intervention may be necessary 5
     • Options include Kirschner wire fixation 5

Post-Procedure Care

1. Pain Management:

   • NSAIDs for pain and inflammation control 5
   • Oral analgesics and ice application for symptomatic relief 5

2. Mobilization and Rehabilitation:

   • Begin progressive range of motion exercises after the immobilization period (typically 3-4 weeks) 5
   • Active finger motion exercises to prevent stiffness 5
   • Full recovery typically expected within 6-8 weeks 5

Important Considerations and Pitfalls

• Nail Bed Integrity: If the nail is avulsed, remove any free-floating proximal portion to prevent irritation and to allow inspection of underlying structures 1

• Complications to Watch For:

  • Infection (though rare with proper technique) 3, 4
  • Nail deformities (uncommon with simple trephination) 3
  • Joint stiffness from prolonged immobilization 5

• Follow-up Importance:

  • Schedule follow-up to assess fracture healing and nail regrowth
  • Average time for nail regrowth is approximately 4 months 3

• Anatomic Restoration: When treating fingertip injuries, the goal should be anatomic restoration to preserve function 6

The evidence strongly supports that simple nail trephination is sufficient for subungual hematomas, even in the presence of distal phalanx fractures, with no need for nail removal or nail bed repair in uncomplicated cases 3.