General Guideline Principles for Distal Phalanx Fractures and
Subungual Hematoma for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Distal Phalanx Fractures and Subungual Hematoma.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Distal Phalanx Fractures and Subungual Hematoma of Hand, Wrist and Forearm Injuries

• Tuft fractures are a frequent occupational injury that typically result in comminuted or transverse fractures and are brought on by a crush injury to the fingertip. They frequently have lacerated nail beds and subungual hematomas.

  Tut fractures typically heal steadily and without issues because of the soft tissue support that the fibrous septae and nail plate offer.

   

• However, crush or avulsion fractures of the proximal base of the distal phalanx may also involve flexor or extensor tendons, requiring surgical intervention.

   

• The extensor tendon’s continuity over the distal interphalangeal joint is lost in a fracture-dislocation injury to the distal phalanx known as a mallet fracture or mallet finger.

   

• When bleeding under the nail occurs after trauma, it is known as a subungual hematoma.

Diagnostic Studies of Distal Phalanx Fractures and Subungual Hematoma

1. Diagnostic Studies of Distal Phalanx Fractures and Subungual Hematoma X-rays

   Diagnostic Studies of Distal Phalanx Fractures and Subungual Hematoma X-rays is recommended to find fractures in the tuft.

   Frequency/Duration – Typically, one set of x-rays is enough. Aside from complicated healing, follow-up x-rays are rarely required.

    

2. MRI / CT / Ultrasound / Bone Scan Imaging

   MRI / CT / Ultrasound / Bone Scan Imaging are not recommended for tuft fracture diagnosis.

Medications of Distal Phalanx Fractures and Subungual Hematoma

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients.

For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even though the majority of research indicates it is only marginally less effective than NSAIDs. There is proof that NSAIDs are less dangerous and just as effective at treating pain as opioids, such as tramadol.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Tuft Fractures Pain

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Tuft Fractures Pain are recommended for the treatment of pain from tuft fractures that is either chronic or subacute.

Indications – NSAIDs are advised as a treatment for the acute, subacute, or chronic pain associated with tuft fractures. First, try over-the-counter (OTC) medications to see if they work.

Frequency/Duration: Many patients might find it reasonable to use as needed. warning signs of

Discontinuation: the symptom’s resolution, the medication’s ineffectiveness, or the emergence of side effects that require stopping.

1. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding are recommended for patients at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors concurrently.

   Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if longer-term treatment is needed.contemplated. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

   Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

   Indications for Discontinuation:Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

    

2. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   The advantages and disadvantages of NSAID therapy for pain should be discussed with patients who have a history of cardiovascular disease or who have multiple cardiovascular risk factors.

    

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended As far as adverse cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

      

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended If necessary, non-selective NSAIDs are preferred to COX-2-specific medications. To lessen the chance that an NSAID will negate the health benefits of low-dose aspirin in patients taking it for primary or secondary cardiovascular disease prevention, the NSAIDs should be consumed at least eight hours or 30 minutes after daily aspirin.

      

3. Acetaminophen for Treatment of Tuft Fractures Pain

   Acetaminophen for Treatment of Tuft Fractures Pain is recommended for the treatment of tuft fracture pain, especially in patients who have NSAID contraindications.

   Indications: any patients who have tuft fractures and are experiencing pain, regardless of how severe it is.

   Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of hepatic toxicity.

    

4. Opioids of Distal Phalanx Fractures and Subungual Hematoma

   Limited Use of Opioids for Acute and Post-operative Pain Management

   Limited Use of Opioids for Acute and Post-operative Pain Management are recommended for brief (less than seven-day) use as an adjunctive therapy to more powerful treatments for the management of acute and post-operative pain.

   Indications: In addition to more effective treatments (especially NSAIDs, acetaminophen, elevation, and splinting), a brief opioid prescription is frequently needed for acute injury and post-operative pain management, especially at night.

   Frequency/Duration: As needed during the day, only at night later, and finally completely discontinued.

   Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids are advised for brief, selective use in post-operative patients, with nighttime use being the main recommendation for achieving post-operative sleep.

    

5. Antiobioitic Prophylaxis

   Antiobioitic Prophylaxis is not recommended antibiotic prophylaxis after trephination for open fractures.

    

6. Tetanus Immunization

   Tetanus Immunization is recommended that tetanus vaccination records be updated as required.

   Indications – if more than 5 years have passed since the last tetanus vaccination, burns or dirty wounds.

Treatments of Distal Phalanx Fractures and Subungual Hematoma

If the nail plate under the eponychium cannot be reduced, the tutt fractures caused by nail avulsion may need to be removed. Typically, simple closures don’t need orthopaedic assistance.

An orthopaedic or hand surgeon is usually needed to treat open fractures with significant soft tissue damage because they are frequently accompanied by chronic pain and disability.

1. Trephination

   Trephination is recommended to treat the subungual hematoma.

    

2. Nail Removal or Nail Bed Laceration Repair

    

   • Nail Removal or Nail Bed Laceration Repair

     Nail Removal or Nail Bed Laceration Repair are not recommended for the treatment of subungual hematoma when the nail bed has not been cut.

      

   • Nail Removal or Nail Bed Laceration Repair are recommended for the treatment of subungual hematoma brought on by nail bed laceration in order to prevent further cosmetic damage.

      

3. Reduction Of The Nail Plate Under the Eponychium

   Reduction Of The Nail Plate Under the Eponychium is recommended in some instances

    

4. Removal of the Nail Plate Under the Eponychium

   Removal of the Nail Plate Under the Eponychium is recommended- if it is impossible to reduce the nail plate underneath the eponychium. Evidence for Trephination and the Use of Laceration Repair or Nail Removal

    

5. Immobilization: Splinting

   Protective splinting of the distal phalanx to the PIP

   Protective splinting of the distal phalanx to the PIP is recommended for fractures.

    

6. Finger splinting of tuft fractures

   Finger splinting of tuft fractures is recommended splinting the finger to stop further pain or damage.

Rehabilitation of Distal Phalanx Fractures and Subungual Hematoma

Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put forth an internal effort to finish a particular exercise or task. The interventions known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their part.

Passive interventions are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active interventions should be prioritised.

To maintain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

To facilitate functional gains, assistive devices may be used as an adjunctive measure in the rehabilitation plan.

Therapy: Active of Distal Phalanx Fractures and Subungual Hematoma

Therapeutic Exercise

Therapeutic Exercise is recommended in certain circumstances to treat tuft fractures. Reasons For the treatment of tuft fractures in some circumstances. Motives behind

Frequency/Dose/Duration –With documentation of ongoing objective functional improvement, the total number of visits may be as low as two to three for patients with mild functional deficits or as high as 12 to 15 for those with more severe deficits.

If there is evidence of functional improvement toward specific objective functional goals, more than 12 to 15 visits may be necessary when there are persistent functional deficits (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities).

A home exercise programme should be created as part of the rehabilitation strategy and carried out alongside the therapy.

Surgery of Distal Phalanx Fractures and Subungual Hematoma

1. Surgery of Distal Phalanx Fractures and Subungual Hematoma

   Surgery of Distal Phalanx Fractures and Subungual Hematoma is recommended for extremely displaced, unable-to-reduce, or unstable fractures.

   With the exception of fractures that cannot be reduced, are extremely displaced, or are unstable, distal phalangeal diaphyseal fractures rarely need surgical fixation. The preferred method of internal fixation is retrograde percutaneous Kirschner-wire fixation.

    

2. Hardware Removal

   Hardware Removal is recommended Hardware removal is advised after it has been implanted in some cases, depending on the doctor’s and the patient’s preferences.

   Indications: in situations where there is 1) protruding hardware, 2) pain related to the hardware, 3) broken hardware on imaging, and/or 4) positive anaesthetic injection response, as per the doctor’s or patient’s preference.

What our office can do if you have Distal Phalanx Fractures and Subungual Hematoma

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.