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.
Subungual Hematoma Management
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.
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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.
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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.
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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.Author: Dr Mirain Phillips, Resident Medical Officer, Waikato Hospital, Hamilton, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof. Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. March 2020.
Subungual haemorrhage is bleeding under a nail where blood is located between the nail matrix and nail plate. Subungual haemorrhage (escape of blood) is also called subungual haematoma (collection of blood).
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The patient may remember an injury leading to intense pain due to the pressure from the pooling of blood in an enclosed space and damage to surrounding tissues. Reactive inflammatory changes, such as swelling and erythema, may be observed around the nail fold shortly after the injury.
Trauma may destroy or fracture the nail plate, resulting in the nail being opaque and yellowish due to detachment from the nail bed (onycholysis). The hyponychium (the skin under the free distal edge of the nail) may appear thickened due to blood between the nail plate and the nail bed.
Subungual haemorrhage may appear reddish, purple, brown, black, or a combination of these colours. The variation in colour is related to the duration and stage of healing [2].
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A clear proximal margin in the nail plate appears within a few weeks due to normal nail growth after the injury and the discoloured nail plate grows outwards.
Nail unit melanoma appears as a pigmented linear or triangular band along the entire length of the nail plate. It develops the following features over time:
No treatment is required for subungual haemorrhage in the majority of cases. In the case of repetitive subungual haemorrhage, precipitating factors should be avoided, such as tight or ill-fitting shoes.
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If subungual haemorrhage is acutely painful (< 48 hours after the injury), trephination can be considered [6, 7]. Small holes are made in the nail plate to decompress and drain the haematoma. This can be done simply with a hot pointed metal implement [6].
Occasionally the nail plate is best removed, and the nailbed surgically repaired. A surgical opinion should be sought if there is an underlying fracture [7] or for biopsy if melanoma cannot be excluded.
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