Subungual hematomas, sometimes referred to as a fingernail or toenail blister, occur following direct blunt trauma to the digit. Examples of mechanism might include dropping something on your tie, slamming your finger in the car door or stubbing your toe. Subsequently, there is bleeding under the nail and hematoma formation. Most patients will report throbbing toe/finger pain with some form of discoloration of the nail. On exam there will be dark or purple discoloration under the nail with some degree of tenderness. It is important to evaluate for other injuries.
A 34 year old patient presents to your clinic for toe pain. She states she hit her big toe really hard on the nightstand the previous evening. She states her nail is really painful and the toe is swollen and blue. Which of the following injury patterns would be the best candidate for trephination?
Simple hematomas can be defined as occuring in isolation. However, many are associated with other injuries such as nailbed lacerations, fingertip avulsions and fractures. One study of subungual hematomas in fingers found about 1/3 were associated with phalanx fractures and nailbed lacerations.[1]Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. 1987 Jul;5(4):302-4. The presence of other injuries can change management.
Crush Injuries Of The Fingertip
Initial management will routinely, but not always involve radiographs depending on mechanism and exam. The vast majority of cases are managed without any surgical intervention. In patients who are asymptomatic or more than 48 hours from presentation, no intervention is typically required. Patients can be treated with NSAIDS and Acetaminophen as needed.
Trephination uses electro-cautery or a large gauge needle to fenestrate the nail over the hematoma and decompress the hematoma. Most patients will tolerate this procedure well and have resolution of symptoms immediately following the procedure. In general, indications include duration less than 48 hours (as longer duration hematomas are likely clotted off and will not aspirate out), and the absence of obvious nailbed laceration, fingertip avulsion or open fractures.
The procedure itself is pretty straight forward. Once the decision is made, electrocautery or an 18 gauge needle can be used. A digital block with a local anesthetic is optional but not necessary. Sterile technique should be used before beginning the procedure. To puncture the nail, place your preferred device on the center of the hematoma and apply gentle pressure. Avoid the lanula and matrix. Withdraw as soon as blood is released from the fenestration. Apply gentle pressure to the sides of the nail to help milk blood out of the fenestration.
Paronychia: Practice Essentials, Background, Epidemiology
Nail removal is indicated if there is associated nailbed avulsion, complex laceration, fingertip or toe avulsion. However, for most patients this procedure is not necessary. This procedure requires a digital block.
Antibiotics are not indicated in most patients, even those with a tuft fracture. Antibiotics should be given in high risk patients such as diabetics or those who are immunocompromised with any open fracture. In kids, a salter harris fracture is also high risk and requires antibiotics. Tetanus prophylaxis is indicated when appropriate. In athletes with a sport related mechanism, consideration can be made co alter footwear to reduce risk.
Following trephination, the athlete should keep the toe dry and clean. It can continue to drain for 24-48 hours. Patients should be counseled to return if there is reaccumulation of the hematoma or evidence of infection.
Distal Phalangeal Fractures
Patients with an isolated subungual hematoma can return to sport and practice immediately without any specific rehabilitation. Patients with nailbed injuries or fractures will require immobilization and a more delayed return to play.
50% were recommended to have nailbed removal, however recent studies have failed to show a difference in short- or long-term outcomes, including the presence of infection or nail deformity with removal vs trephination.[3]Roser SE, Gellman H, Comparison of nail bed repair versus nail trephination for subungual hematomas in children, J Hand Surg 24(6):11661170, 1999. [4]Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991 May;9(3):209-10. Finally, complications although rare include poor nailbed cosmesis (including deformity or loss), onycholysis (separation of the nail plate from the nail bed), and infection.
Best answer is D. Trephination is the use of cautery, needle or otherwise to decompress a hematoma below the nail. Most patients tolerate this procedure well and have immediate improvement in pain. The literature is not clear on which patients should not receive trephination, however the rest of the choices are not as good of a candidate. Soft contra-indications include displaced fractures, intra-articular fractures, extensive nail bed injuries, infected wounds, and polytrauma. In these patients, you should strongly consider involving orthopedics or podiatry.
Subungual Hematoma: Symptoms, Causes, Treatments
Roser SE, Gellman H, Comparison of nail bed repair versus nail trephination for subungual hematomas in children, J Hand Surg 24(6):11661170, 1999.
Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991 May;9(3):209-10.Subungual hematoma or bleeding under a nail plate, is a purple mark under the nail due to bleeding or bruising. Subungual hematoma results in painful or unnoticed purplish-black discoloration. The discoloration may persist for months as the nail carries the blood with it as it grows out.
Subungual hematoma is usually caused by a traumatic injury as in hitting your thumb with a hammer or stubbing a toe. Subungual hematoma can also occur from wearing tight-fitting shoes which trap blood in the toes leading to an increased pressure within the blood vessels of the toes. In either case, the injury leads to the breakage of small blood vessels underneath the nail which leak blood into a potential space below the nail that causes discoloration of the nail and intense pressure.
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Initially the injury may only hurt. The nail may feel sore or tender to the touch. As the blood pools under the nail the pressure from the blood can cause severe pain. The pressure caused by blood underneath the nail may result in the affected nail lifting off the finger or toe. The color under the nail will change over time initially red to purple and later to dark brown and black as the blood clots. The pain usually resolves days after the injury and the nail looks worse than it feels.
There are a few reasons to seek medical attention: if bleeding does not stop, if the pain becomes too intense, or if there is significant injury to the base of the nail. Depending on the manner of injury, issues to be aware of would be; a deep cut or laceration to the skin of the finger or toe underneath the nail that may require stitches as well as taking an x-ray to determine if the bone of the finger or toe involved is broken. If necessary the pressure caused by the hematoma can be resolved by a medical professional using a technique called trephination. This is done by using a sharp instrument to pierce the nail and drain the blood which relieves the pain. Drainage or removing the nail is discouraged from being attempted by the public because this could lead to further complications of infection, additional trauma, slowing of the healing process, or leaving the finger or toe vulnerable.
Over the course of several months a new nail replaces the damaged, discolored nail. There usually is no need for further treatment or follow up.
Simple Diagnostic Tests For Subungual Pigmentation
Usually the treatment is minimal and consists of rest, ice, elevation, and compression of the finger or toe. Over the counter pain medication can be given if needed. Elevation and the use of ice help to reduce the swelling and further pain. Placing ice directly on the affected nail could cause further injury, so wrapping ice in a cloth towel and applying it to the affected area works best. Compression can further reduce the bleeding underneath the nail.
Regardless of treatment the hematoma will eventually be resorbed by the body and a new nail will grow out. On average the nail takes 6 to 9 months to grow completely out. Toenails take about 12 months to grow back. A complication to be aware of is damaging the cells that re-grows the nail (the nail matrix). If the nail matrix is damaged the nail will grow incorrectly or may not re-grow a nail. The new nail will probably have grooves or ridges and be somewhat misshapen. This may be permanent.
For more serious nail injuries, you should go to an urgent care center or the emergency room. They will stop the bleeding and clean the wound. Usually, the nail and finger or toe will be numbed with medicine before it is treated.
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If you broke a bone in your finger or toe along with the nail injury, it will take about 4 weeks to heal.
Small or painless hematomas and hematomas that are already draining need not be trephined. Hematomas confined to the lunula should not be trephined. If you suspect underlying nail-bed injury or fracture of the phalanx, trephining should not be attempted.
Draining is indicated to relieve pain caused by subungual hematomas when the nail edges are unaffected. The decision to perform this procedure is based
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