Subungual hematoma

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Background

  • Collection of blood under the nail
  • 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]
  • Types
    1. Simple - no nailbed dislocation or evidence of open fracture
    2. Complex - associated with fracture or nail plate disruption
Subungal hematoma
All blood has been expelled through the trephination hole

Clinical Features

  • Blood trapped under nail

Differential Diagnosis

Hand and finger injuries

Evaluation

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

Management

Simple

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

Complex

Disposition

  • Discharge

See Also

References

  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