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Three Part Question

In [patients with a closed distal phalangeal fracture] does [trephining an associated subungal haematoma] increase [the risk of infection]?

Clinical Scenario

A 28 year old patient presented to the emergency department having caught her left hand in a fire door at work. X-rays revealed crush fractures to her fourth and fifth distal phalanges. She had an associated subungal haematoma of her fourth finger. The skin and nail bed margin were intact. You wonder is it safe to trephine this subungal haematoma or would converting this closed fracture to an open fracture increase the risk of infection.

Search Strategy

Medline 1966-week 3/09/04 using the Ovid interface.
[exp fractures OR fractur$.af OR break.af OR broken.af] AND [exp finger injuries OR finger.af OR phalan$.af OR digit.af] AND [exp hematoma OR hematoma.af OR haematoma.af] LIMIT to English language.

Search Outcome

Altogether 18 papers were found of which 16 were irrelevant or of insufficient quality to include. The remaining 2 papers directly answering the question are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Seaberg DC et al, 1991, USA	48 patients with a subungal haematoma over a 2 year period	Prospective observation	Cosmetic effect & infective complications after trephining subungal haematoma with electrocautery	No complication of infection or osteomyelitis in any patients in the study	Small study No control Only used electrocautery
Roser SE & Gellman H, 1999, USA	52 children of which 11 had simple trephination over a 2 year period 11 out of 26 had tuft fracture	Sequential study	No infection reported	No infection in either group	Only 45% of prescriptions for prophylactic antibiotics were fulfilled Unknown what % of participants that had trephination had underlying crush fracture Unknown what technique (needle or electrocautery) used for each group

Comment(s)

Studies were limited and there were no randomised control trials but the studies quoted came to the same conclusion that there is no increased risk of infection when trephining a subungal haematoma with an underlying crush fracture.

Clinical Bottom Line

In patients with closed distal phalangeal fractures and an overlying subungal haematoma, it is safe to trephine the haematoma without an increased risk of infection. Antibiotics were shown to be of no clinical significance.

References

1. Seaberg DC, Angelos WJ, Paris PM. Treatment of Subungal Hematomas With Nail Trephination: A Prospective Study. Am J Emerg Med 1991;9(3):209-210.
2. Roser SE, Gellman H. Comparison of Neil Bed Repair Versus Nail Trephination for Subungal Hematomas in Children. J Hand Surg [Am] 1999;24(6):1166-1170.