An accurate physical examination, including radiographic studies to establish the presence of bony fractures and to assist in wound exploration, must be expeditiously performed. The injured digit is prepared in a sterile field and irrigated with normal saline solution. Hemostasis of the digit may be achieved by a finger tourniquet and to increase the effectiveness of the digital block. The exploration of wound and surgical treatment are performed under a digital block with Lidocaine.
Management of subungual hematomas largely depends on their size, location, and presentation. Hematomas are usually evacuated by creating a small puncture hole through the nail plate by using a number-18 needle, a paper clip, a drill, and an acute-tipped scalpel heated over an alcohol lamp or a handheld electrocautery unit. A slow, constant pressure is applied to the center of the nail plate to puncture the plate and to allow drainage of the hematoma. After complete drainage, adherence of the nail plate to the nail bed is ascertained by bogging down the plate with a tight bandage. It provides almost immediate pain relief, and the risk of complications, such as infection and nail dystrophy, are absent with this procedure.
If the hematoma is not removed, nail attachments are loosened, and the nail falls off to be replaced by a new healthy nail several weeks after the trauma. Large or total hematomas may indicate a fractured distal phalanx with significant lacerations of the matrix and the nail bed, radiography is indicated to exclude fracture. When evacuating a large hematoma, the nail plate is first avulsed. The nail bed and matrix are carefully explored and examined, and the hematoma is removed. Any laceration of the nail bed is closed with an absorbable suture. The avulsed plate should be cleaned, trimmed, and reattached to the nail bed with sutures. Stitches are removed in 10 days, when the nail is firmly adherent to the nail bed.
Repair of simple lacerations
Superficial lacerations that are limited to the nail plate and involve less than 3 mm of the nail bed usually heal without surgical repair as the injured nail grows out. Larger lacerations of the nail bed (due to displacement of the nail plate) with phalangeal fracture must be surgically repaired.
Repair of complex or stellate lacerations
During repair, a complete nail avulsion is performed to fully expose the nail matrix. After avulsion, the wound is carefully debrided. Then, the wound edges are accurately reapposed. To avoid future nail deformity, the nail root and the nail bed are carefully aligned and replaced on the finger by using 6-0 absorbable sutures. Improper management of a complex lacerating injury may result in nail deformities. Partial avulsive lacerations of the nail bed with loss of nail plate adherence are surgically treated with nail matrix grafts. In cases of extensive avulsive lacerations, a flap closure is performed.
Repair of fractures
Stable fractures that are not displaced do not require manipulation by reduction; however, they should be protected from potential trauma. If a fracture is unstable, it must be immobilized and reduced through closed reduction with external splinting of the injured finger to the adjacent digit.
Treatment of splinter hemorrhage
In a young, healthy patient, splinter hemorrhages are explained by a history of minor trauma and require no further investigation. Treatment of splinter hemorrhages should be directed at resolving the underlying cause.