New York State Medical Treatment Guidelines for Distal Phalanx Fractures and Subungual Hematoma in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board present fundamental principles for addressing Distal Phalanx Fractures and Subungual Hematoma. These directives are crafted to assist healthcare professionals in identifying appropriate therapeutic approaches within the context of a comprehensive assessment.

Healthcare professionals with expertise in managing Distal Phalanx Fractures and Subungual Hematoma can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic methods for their patients.

It is essential to underscore that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of Distal Phalanx Fractures and Subungual Hematoma should involve collaboration between the patient and their healthcare provider.

Fingertip or Distal Phalangeal Fractures

Frequently identified as the most common hand fractures, fingertip or distal phalangeal fractures, with the tuft being the most prevalent, are often the result of crush injuries. These injuries, commonly occurring in occupational settings, lead to comminuted or transverse fractures and are frequently accompanied by nail bed lacerations and subungual hematoma.

Due to the soft tissue support of fibrous septae and the nail plate, tuft fractures are generally stable and heal without complications. However, crush or avulsion fractures involving the proximal base of the distal phalanx may also affect flexor or extensor tendons, necessitating surgical intervention.

Another common injury is the mallet fracture or mallet finger, a fracture-dislocation of the distal phalanx resulting in the loss of continuity of the extensor tendon over the distal interphalangeal joint. Subungual hematoma, involving blood trapped under the nail after trauma, is another relevant condition.


Diagnostic Studies


Recommended for diagnosing tuft fractures. Generally, obtaining x-rays once is sufficient, and follow-up x-rays are rarely necessary except for cases of complicated healing.

MRI / CT / Ultrasound / Bone Scan Imaging

Not recommended for diagnosing tuft fractures. There is insufficient evidence supporting the use of MRI, CT, ultrasound, or bone scan imaging for diagnosing tuft fractures.



For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen may be a reasonable alternative for patients who cannot take NSAIDs, although evidence suggests it is slightly less effective.

NSAIDs for Treatment of Acute, Subacute, or Chronic Tuft Fractures Pain

Recommended for treating pain associated with tuft fractures. Over-the-counter agents may be tried first, and NSAIDs can be used as needed for many patients.

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

Recommended for concomitant use of cytoprotective drugs in patients at high risk of gastrointestinal bleeding.

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

Recommended that patients with known cardiovascular disease or multiple risk factors for cardiovascular disease discuss the risks and benefits of NSAID therapy for pain. Acetaminophen or aspirin is considered safer regarding cardiovascular adverse effects.

Acetaminophen for Treatment of Tuft Fractures Pain

Recommended for treating pain associated with tuft fractures, especially in patients with contraindications for NSAIDs.


Recommended for limited use (less than seven days) for acute and post-operative pain management as adjunctive therapy. Opioids can be prescribed as needed throughout the day, with a focus on nocturnal use, before gradually reducing.

Antibiotic Prophylaxis

Not recommended for post-trephination antibiotic prophylaxis for open fractures. There is insufficient evidence to support the use of antibiotic prophylaxis for open fractures after trephination.

Tetanus Immunization

Recommended to update tetanus immunization status as necessary. Tetanus immunization is indicated for wounds that are not clean or burns if more than five years have passed since the last tetanus immunization.


Treatment of Tuft Fractures

Orthopedic Assistance for Uncomplicated Closures

For tuft fractures associated with nail avulsion, addressing the nail plate under the eponychium may necessitate reduction or removal if reduction is not feasible. Generally, orthopedic assistance is not essential for straightforward closures.

Open Fractures with Extensive Soft Tissue Damage

Open fractures with significant soft tissue damage often lead to chronic pain and disability, requiring assistance from an orthopedic or hand surgeon.


Trephination and Nail Management


Recommended for managing subungual hematoma.

Nail Removal or Nail Bed Laceration Repair

Not recommended for managing subungual hematoma without nail bed laceration. However, it is recommended for cases associated with nail bed laceration to prevent future cosmetic defects.

Reduction of the Nail Plate Under the Eponychium

Recommended in select cases.

Removal of the Nail Plate Under the Eponychium

Recommended in select cases if reduction of the nail plate under the eponychium cannot be performed.


Immobilization: Splinting

Protective Splinting of the Distal Phalanx to the PIP

Recommended for fractures. Duration is approximately three weeks.

Finger Splinting of Tuft Fractures

Recommended for preventing further discomfort or injury.

Reduction of Significantly Displaced Fractures

Recommended for reduction and splint immobilization in relatively uncommon significantly displaced fractures. Referral to an orthopedic surgeon may be indicated if reduction cannot be achieved.



Rehabilitation for work-related injuries should focus on restoring functional ability for daily and work activities. Active therapy, involving internal effort from the patient, is emphasized over passive interventions.

Therapy: Active

Therapeutic Exercise

Recommended in select cases for treating tuft fractures. Joint mobilization therapy may be useful for complicated injuries or post-surgical fixation.



Surgical Intervention

Recommended for extremely displaced, unreduced, or unstable fractures of the distal phalanx. Distal phalangeal diaphyseal fractures rarely require operative fixation, except in specific cases.

Hardware Removal

Recommended in select cases where hardware removal is preferred, such as protruding hardware, pain attributed to the hardware, broken hardware on imaging, or a positive anesthetic injection response.


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