Management of Proximal Finger Hematoma
For a simple proximal finger hematoma in patients on anticoagulants, continue anticoagulation without interruption unless there is evidence of compartment syndrome, expanding hematoma threatening neurovascular structures, or the INR is supratherapeutic (>3.0).
Initial Assessment
Determine anticoagulation status immediately:
- Check INR if on warfarin (target therapeutic range is typically 2.0-3.0) 1
- Document timing of last anticoagulant dose
- Assess for signs of compartment syndrome: severe pain out of proportion, paresthesias, pallor, pulselessness 1
Management Algorithm
If INR is Therapeutic (2.0-3.0) or Patient on Aspirin Alone:
Continue anticoagulation without modification 1. The risk of thromboembolic complications from discontinuing anticoagulation (5-7% case fatality rate for recurrent thromboembolism) outweighs the risk of bleeding from a simple finger hematoma (3% annual major bleeding risk with 0.6% case fatality) 1.
- Apply ice and elevation
- Use paracetamol (≤2g daily) for pain control as the preferred analgesic 2
- Monitor for expansion over 24-48 hours
- No surgical intervention needed for simple hematomas 3
If INR is Supratherapeutic (>3.0):
Hold warfarin temporarily until INR returns to therapeutic range 1, 4. Bleeding at INR >3.0 is frequently associated with trauma or underlying lesions 1.
- Do not give vitamin K for minor bleeding with INR <5.0 - simply hold warfarin 4
- Resume warfarin once INR drops to 2.0-3.0 range 1
- Monitor INR within 24 hours
If Hematoma is Expanding or Causing Compartment Syndrome:
This constitutes major bleeding requiring reversal 5, 6:
- For warfarin: Administer 5-10 mg parenteral vitamin K1 plus four-factor prothrombin complex concentrate (PCC) 25-50 units/kg for immediate reversal 4, 5, 6
- For dabigatran: Give idarucizumab 5g IV 5
- For apixaban/rivaroxaban: Give andexanet alfa per protocol 5
- Surgical decompression if compartment syndrome confirmed
Critical Pitfalls to Avoid
Do not routinely discontinue anticoagulation for simple finger hematomas - the thromboembolic risk (12% annual recurrence rate off anticoagulation) far exceeds bleeding risk from minor soft tissue bleeding 1. Patients may return to pretreatment thrombotic status following rapid reversal 4.
Avoid NSAIDs for pain control - use paracetamol instead at lowest effective dose 2. If requiring >2g daily paracetamol, check INR within 5-7 days 2.
Do not give fresh frozen plasma as first-line reversal - it carries hepatitis and viral disease risk and is less effective than PCC 4, 6. Use four-factor PCC for warfarin reversal instead 5, 6.
Special Considerations for Anticoagulated Patients
The elderly (≥65 years) have higher bleeding risk even at therapeutic INR levels and may require closer monitoring 1. Patients with history of gastrointestinal bleeding, stroke, renal insufficiency, or anemia have additive bleeding risk factors 1, 7.
Resume anticoagulation as soon as bleeding is controlled (typically 24-48 hours for simple hematomas) to minimize thromboembolic risk 1, 4. The period off anticoagulation should be minimized to 2-3 days maximum 1.