Subungual hematoma

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Subungual hematoma is a collection of blood under the nail and and the nail bed. There is a strong association with distal phalanx fractures. In the past, complete nail removal and exploration and closure of possible nail bed lacerations was performed. A prospective study of 52 children supports management with trephination alone for any size hematoma.[1]

Subungal hematoma
All blood has been expelled through the trephination hole


  • Simple - no nailbed dislocation, no evidence of an open fracture
  • Complex - associated with a fracture or a nail plate disruption

Clinical Features

  • Blood trapped under nail

Differential Diagnosis

Hand and finger injuries


  • Clinical diagnosis
    • Evaluate percentage of nail bed involved, test extensor/flexor tendons, distal cap refill



  1. Trephination
    • Cleanse with povidone-iodine solution (not flammable alcohol)
    • Handheld cautery works best - no anesthesia is required
    • Alternatively a needle spun in a drilling fashion
    • Sharp object (i.e. safety pin) heated with flame in an austere environment
  2. If a fracture is present, the digit should be splinted
  3. Instruct patients to soak affected finger in warm water BID-TID x7d
  4. Prophylactic antibiotics are not needed after trephination of uncomplicated hematomas [2]


  1. Nail removal only recommended if there is associated nail avulsion or nail fold disruption[3]
  2. Repair nailbed laceration using absorbable sutures


  • Outpatient

See Also


  1. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg. 1999;24(6):2266-1170.
  2. Holtzman L. Incision and Drainage. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014.
  3. Seaberg DC, ANgelos WJ, et al. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991; 9(3):209-210