CASE                               11                               

A 26-year-old female was traveling with her fiancé. At a rest stop, as she got out of the car, he accidentally shut the car door on her left ring finger. There was immediate swelling and bleeding, and after application of first aid, the finger remained swollen and the patient is now here to see you. Radiographs do not show any obvious bony abnormality.

Clinical examination of the finger reveals a swollen finger, a tender pulp, and a subungual hematoma, which occupies approximately 50% of the nail plate. The next step in management would be:

1. Drainage of the subungual hematoma

2. Removal of the nail plate and repair of the nail bed

3. Reassurance and splinting for comfort

4. Open repair, release of the eponychial fold, exploration of the sterile and germinal matrix, and replacement of the nail plate as a stent

Discussion

The correct answer is (C). As described, the patient does not have severe discomfort. In the absence of an obvious fracture, the only indication for drainage of a subungual hematoma would be for pain control where the patient has excruciating pain from a subungual hematoma. Since that is not the case, this subungual hematoma does not need to be drained. Traditional teaching has suggested that if a subungual hematoma exceeds 30% to 40% of the size of the nail plate, then the nail should be removed and the nail bed should be repaired. However, longitudinal studies have shown that removal of the nail plate and repair of the nail bed does not appear to influence nail growth positively in most patients. Therefore, in the absence of a fracture and if the nail plate is well fixed, irrespective of the size of the hematoma, not only does the hematoma not need to be drained, but the nail plate should not be removed, and the nail bed does not need repair. In this situation,

the patient’s finger may be splinted for comfort for a few days, elevation and icing is recommended, and range of motion is started at the earliest possibility.

At the same time that the patient injured her ring finger, the middle finger also sustained an injury. The middle finger radiographs, however, show that she has a fracture of the distal phalanx which is essentially nondisplaced and a subungual hematoma which occupies 50% of the size of the nail plate.

The most appropriate management for the middle finger would be which of the following?

1. Nail plate removal and repair of the nail bed

2. Drainage of the hematoma

3. Pinning of the distal phalanx

4. Splinting for comfort and range of motion to be started as soon as comfortable

Discussion

The correct answer is (D). Although the patient has a hematoma which occupies 50% of the nail plate, the description of this finger suggests that the fracture of the distal phalanx is completely nondisplaced. In such situations, there is no indication to remove the nail plate and repair the nail bed. A well-fixed nail plate and nondisplaced fracture of the distal phalanx essentially form a splint for the nail bed and allow the fracture and nail bed to heal in as anatomical position as possible. By removing a well fixed nail plate, the nail bed is destabilized and the support that the nail plate would afford for distal phalangeal fracture is also lost. Therefore, the nail plate is not to be removed in this situation. the patient would simply benefit from a splint and starting range of motion program as soon as the fracture gets more comfortable which is usually around 2 to 3 weeks.

During the same accident, the patient also sustained a fracture of the index finger. The index finger showed a fracture of the distal phalanx which was displaced. The fracture was at the base, and the nail plate was elevated in the proximal eponychial fold from which there was bleeding.

The most appropriate management for this injury would be which of the following?

1. Removal of the nail plate, replacement of the distal phalanx, reduction of the distal phalangeal fracture, fixation with Kirschner wire, open repair of the nail bed, and repair of the nail plate or stenting open the eponychial fold

2. Closed reduction and wire fixation

3. Splinting for comfort

4. Volar approach plate fixation of the distal phalanx

Discussion

The correct answer is (A). This digit has a displaced fracture with proximal avulsion of the nail plate from the eponychial fold. This situation involves an injury to the germinal matrix of the nail bed and one which is unlikely to heal in the most optimal circumstances unless the distal phalanx is repositioned anatomically, fixed, and then the nail bed is repaired meticulously. To do this, the nail plate is initially removed. The laceration and the nail bed are carefully assessed. If necessary, small incisions are made in the lateral eponychial folds so that the eponychial fold can be folded back. After irrigation and debridement of the fracture site, it is reduced and carefully pinned with a wire. Then, the nail bed is repaired carefully with absorbable sutures, usually chromic catgut. The nail plate is cleaned and repositioned in the nail fold to act as a stent to keep it open in order for the new nail to grow back. The patient should be cautioned about unpredictability of nail growth, that nail growth can take 6 months to stabilize, and to understand the final outcome from a nail bed repair.

Objectives: Did you learn...?

Idenftify indications for subungal hematoma drainage? Treat a distal phalanx fracture?