What is the correct management for a 60% subungual hematoma with an underlying tuft fracture?

Management of 60% Subungual Hematoma with Underlying Tuft Fracture

For a 60% subungual hematoma with an underlying tuft fracture, perform nail trephination for pain relief, followed by conservative fracture management with protective splinting, wound care, and close monitoring for infection.

Immediate Management

Hematoma Drainage

• Perform trephination to evacuate the hematoma and relieve pressure-related pain 1, 2
• The procedure is indicated when the hematoma causes significant pain, regardless of the presence of an underlying fracture 3
• Multiple effective techniques exist:
  • Hand-held cautery provides precise, painless penetration of the nail plate 4
  • 29-gauge insulin syringe needle inserted close to the nail plate minimizes discomfort 5
  • Controlled drill trephination prevents breaching the nail bed 6

Wound Assessment and Cleaning

• Thoroughly clean the wound with antiseptic solutions such as povidone-iodine or dilute vinegar soaks to remove debris and prevent infection 2
• Evaluate whether the nail is partially avulsed or severely damaged 2
• If the nail bed requires repair or if there is significant nail damage, complete nail removal may be necessary to properly assess and treat the underlying structures 2

Fracture Management

Conservative Treatment

• Tuft fractures are managed conservatively with protective splinting as they are stable injuries that heal well without surgical intervention 2
• The fracture itself does not require operative fixation
• Immobilization protects the healing digit and prevents additional trauma 2

Nail Bed Considerations

• If nail bed repair is performed, replace the original nail or a substitute under the proximal nail fold to prevent adhesions and maintain the nail fold space 2

Wound Care Protocol

Daily Care

• Perform antiseptic soaks with dilute vinegar or 2% povidone-iodine for 10-15 minutes twice daily during the healing period 2
• Keep the wound clean and dry, changing dressings regularly 2
• Monitor closely for signs of infection including increased pain, redness, swelling, or purulent drainage 2

Activity Restrictions

• Avoid activities that could cause additional trauma to the healing nail for at least 2-4 weeks 2
• Protective splinting should remain in place during this period

Follow-up and Monitoring

Short-term Follow-up

• Reassess wound healing at 2 weeks post-procedure to determine if additional interventions are needed 2
• Evaluate for signs of infection, which can occur in up to 25% of cases and may require specific antimicrobial therapy 2

Long-term Expectations

• The damaged nail will typically grow out and be replaced by normal nail over approximately 6 months for fingernails and 12 months for toenails 1
• For persistent pain or drainage beyond 2-4 weeks, consider surgical re-evaluation 2

Management of Complications

Granulation Tissue

• If granulation tissue forms during healing, perform scoop shave removal with hyfrecation or silver nitrate application 2
• For recurrent or treatment-refractory cases with significant inflammation, consider intralesional triamcinolone acetonide 2

Infection Management

• Obtain bacterial/viral/fungal cultures if infection is suspected 7
• Begin oral antibiotics with anti-staphylococcus aureus and gram-positive coverage if infection develops 7
• Secondary bacterial or mycological superinfections may require specific antimicrobial therapy 2

Critical Pitfalls to Avoid

• Do not delay trephination in painful hematomas—the procedure provides immediate relief and prevents complications from sustained pressure 3, 4
• Do not assume the fracture requires surgical fixation—tuft fractures are inherently stable 2
• Do not neglect infection surveillance—up to 25% of cases develop secondary infections requiring treatment 2
• Do not remove protective splinting prematurely—maintain immobilization for at least 2-4 weeks 2