For subungual hematoma evaluation, what imaging study should be obtained when the hematoma involves more than 50% of the nail?

• A. X-ray of the finger
• B. MRI of the hand
• C. CT scan
• D. Ultrasound

Answer: (A)

When a subungual hematoma involves more than half of the nail, there’s a real concern for an underlying distal phalanx fracture. The best initial imaging to obtain is a plain X-ray of the finger, because it quickly and reliably shows whether a fracture is present, which guides treatment like immobilization or nail bed management. Other imaging methods—MRI, CT, or ultrasound—aren’t first-line here: MRI can detect occult fractures but isn’t needed upfront, CT is usually unnecessary for straightforward cases and carries more radiation, and ultrasound is less dependable for identifying distal bone injuries. If the X-ray is negative but suspicion remains high, MRI can be considered to look for occult fracture.