Recommended Treatment for Subungual Hematoma with Undisplaced Tuft Fracture
Perform nail trephination and apply a protective splint (Option B). This is the appropriate treatment for this patient's simple subungual hematoma with an undisplaced tuft fracture.
Treatment Rationale
Nail trephination alone is sufficient regardless of hematoma size or presence of an undisplaced fracture. A prospective study with 10-month follow-up of 47 subungual hematomas demonstrated that trephination without nail removal resulted in zero cases of infection, osteomyelitis, or major nail deformities, even when fractures were present 1. This directly contradicts older teaching that advocated nail removal and nail bed repair for large hematomas or those associated with fractures.
Key Management Steps
- Drain the hematoma immediately using electrocautery, a heated paperclip, or an extra-fine 29-gauge needle inserted close to the nail plate to minimize pain 1, 2, 3
- Immobilize the digit with a protective splint to stabilize the undisplaced tuft fracture 1
- Verify tetanus status and administer 0.5 mL tetanus toxoid intramuscularly if immunization is outdated or unknown 4
Why Other Options Are Incorrect
Nail Removal and Nail Bed Repair (Option A)
This is unnecessary and overly aggressive for simple subungual hematomas. The prospective study explicitly demonstrated that nail removal with suture repair of the nail bed is not required regardless of hematoma size (this patient has 60% involvement) or presence of fracture 1. Nail removal increases patient discomfort, prolongs healing time, and provides no additional benefit.
Single Dose IV Antibiotics (Option C)
Prophylactic antibiotics are not indicated for simple subungual hematomas after trephination. A systematic review found no evidence supporting antibiotic prophylaxis for trephined subungual hematomas 5. The nail bed is not considered an open fracture requiring antibiotics unless there is a nail bed laceration with significant soft tissue disruption, which is not described in this case 1.
Operative Washout and Repair (Option D)
This is grossly excessive for an undisplaced tuft fracture with intact nail. Operative intervention would only be considered for displaced fractures requiring reduction, significant nail bed lacerations requiring repair, or evidence of infection—none of which are present here 1.
Expected Outcome and Follow-up
- The patient should experience immediate pain relief after trephination 1, 3
- The damaged nail will grow out and be replaced over approximately 4 months for fingernails 1, 6
- No routine follow-up is necessary unless signs of infection develop (increasing pain, redness, swelling, purulent drainage, or fever) 4
Common Pitfall to Avoid
Do not remove the nail based solely on hematoma size or presence of an undisplaced fracture. The traditional "50% rule" (removing nails for hematomas >50% of nail surface) has been definitively disproven by prospective evidence showing excellent outcomes with trephination alone regardless of size 1.