Letters to the Editor

Treatment of Subungual Hematoma

TO THE EDITOR: The article "Fingertip Injuries"¹ suggests that the appropriate treatment of a subungual hematoma with a distal tuft fracture is decompression with "two to three weeks of splinting." I was taught not to open the subungual hematoma in the presence of a fracture because this would convert a simple closed fracture to an open fracture and thus complicate management. I was also instructed by an orthopedist that, in his opinion, such management was tantamount to malpractice. Was I instructed incorrectly?

KIRK G. WATKINS, M.D.
St. George Sleep Medicine Center
251 W. Hilton Drive Ste 107
St. George, UT 84770-2227

REFERENCE

1. Wang QC, Johnson BA. Fingertip injuries. Am Fam Physician 2001;63:1691-6.

EDITOR'S NOTE: This letter was sent to the authors of "Fingertip injuries," who declined to reply.

Management of Nail Bed Lacerations

TO THE EDITOR: I read with keen interest the fine review by Drs. Wang and Johnson, entitled "Fingertip Injuries."¹ However, I disagree with the authors' proposal for the management of nail bed lacerations. In the presence of a subungual hematoma of at least 50 percent, they recommend removal of the nail with exploration for nail bed laceration and, if found, primary repair. This technique is believed to reduce the possibility of an unacceptable cosmetic or functional nail. I disagree with their statement that "attention to detail (in this regard) is critical in treating nail bed lacerations."

This dogma regarding subungual hematomas and management of nail bed lacerations is a standard and widely disseminated notion that has been in orthopedic literature for years. However, there is no substantive proof for the technique's effectiveness or efficacy in preventing post-traumatic "ridged nail," "split-nail" deformity, an irregular nail surface, or failure of the nail plate to adhere to the nail bed.

Although this issue is controversial and textbook recommendations are mixed,^2,3 some evidenced-based data show that primary repair of nail bed lacerations is probably not necessary. If the nail plate is partially avulsed but is firmly attached to the nail matrix, exploring the nail bed is difficult and probably unwarranted.⁴ Even in the presence of significant subungual hematoma, with or without tuft fracture, the nail need not be routinely removed to search for nail bed laceration, as long as the nail is adherent and disruption of the surrounding tissue is minimal.⁵ A good cosmetic and functional outcome can be expected.

In a small, prospective study, Roser and Gellman⁶ compared outcomes of two groups of patients with fingertip injuries; one group was managed with surgery, and the other was managed without surgery. The first group consisted of 26 consecutive patients, aged eight months to 15 years, with crush injuries resulting in subungual hematomas involving more than 25 percent of the nail bed, with an intact nail and nail margin, who underwent operative repair under digital block. The second group included 26 consecutive patients, aged six months to 20 years, with 27 similar finger injuries managed nonoperatively, with either trephination (11 fingers) or observation without evacuation of the hematoma (16 fingers). Mean follow-up exceeded two years in both groups.

In the operative group in this study,⁶ 75 percent of patients had subungual hematomas in excess of 75 percent and tuft fractures were present in 12 cases. In the nonoperative group, one third of the patients had subungual hematomas in excess of 75 percent and tuft fractures were present in 11 cases. Transient abnormalities were noted in three of the 26 nails in the operative group, and one additional nail exhibited insignificant cosmetic abnormality. One patient in the nonoperative group exhibited a transient nail depression. There were no infections. Notably, the average charge per patient was $1,263 in the operative group, compared with $283 per patient in the nonoperative group.

Based on the results in this series, it would certainly appear that routine nail plate removal and nail bed exploration is not required for patients sustaining subungual hematomas after a crush injury, as long as the nail and nail margins are intact.

EDWARD L. FIEG, D.O.
Division of Emergency Medicine
Washington University School of Medicine
1 Barnes-Jewish Plaza
St. Louis, MO 63110

REFERENCES

1. Wang QC, Johnson BA. Fingertip injuries. Am Fam Physician 2001;63:1961-6.
2. Anostosia RE, Lyn E. The hand. In: Rosen P, Barkim R, eds. Emergency medicine: concepts and clinical practice. 4th ed. St. Louis: Mosby, 1998:659.
3. Shepherd SM, Magdy A. Hand, wrist and elbow injuries. In: Harwood-Nuss A, Wolfson AB, eds. The clinical practice of emergency medicine. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001:573.
4. Selbst SM, Magdy A. Minor trauma: lacerations. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine. 4th ed. Philadelphia: Lippincott Willliams & Wilkins, 2001:1493.
5. Lammes RL, Trott AT. Methods of wound closure. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 2nd ed. Philadelphia: Saunders, 1998:594.
6. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg 1999;24:1166-70.

EDITOR'S NOTE: This letter was sent to the authors of "Fingertip injuries," who declined to reply.

Corrections

Question 8 in "Clinical Quiz" (November 1, 2000, page 1958), pertaining to the article "Acute Brachial Plexus Neuritis: An Uncommon Cause of Shoulder Pain," was unclear. The best answer for Question 8 is A; osteophytes are present on radiographic studies. Because it is possible to have a radiculopathy involving multiple root levels, B is a possible correct answer, but it would not be the best response because the situation is extremely unusual. The question is printed below; the correct answer is A.

Q8. Which one of the following conditions makes it difficult to distinguish acute brachial plexus neuritis from cervical radiculopathy?
		A.	Osteophytes are present on radiographic studies.
		B.	The radiculopathy involves multiple neurologic levels.
		C.	There is a long delay between the patient's pain and neurologic deficits.
		D.	Sensory loss occurs in a single dermatome.
		E.	There is a history of antecedent trauma.

Question 2 in "Clinical Quiz" (September 15, 2001, page 920), pertaining to the article "Initial Management of Breastfeeding," was incorrectly worded. The infant's age in answer choice A was stated as eight to 10 days, which created two correct answer choices. Choice A should have been stated as four days, which would have been an obviously incorrect answer. The correctly worded question is printed below. The correct answer remains C.

Q2. Which one of the following is a sign of adequate breastfeeding?
		A.	Infant's weight returns to the birth weight by four days.
		B.	Infant continues sucking without pauses.
		C.	Infant has wet diapers at least six to eight times a day.
		D.	Infant wants feedings three to four times a day.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.