Subungual hematoma: Difference between revisions

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==Background==
==Background==
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.<ref>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.</ref>
*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.<ref>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.</ref>
*Atraumatic subungual hematoma may be caused by melanoma or Kaposi's sarcoma


===Types===
[[File:Subungal hematoma.jpg|thumb|Subungal hematoma]]
[[File:Subungal hematoma.jpg|thumb|Subungal hematoma]]
[[File:Post trephonation.jpg|thumb|All blood has been expelled through the trephination hole]]
#Simple: No nailbed dislocation or evidence of open fracture
#Complex: Aassociated with fracture or nail plate disruption


===Types===
{{Fingertip anatomy}}
*Simple  - no nailbed dislocation, no evidence of an open fracture
*Complex - associated with a fracture or a nail plate disruption


==Clinical Features==
==Clinical Features==
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{{Hand and finger injury DDX}}
{{Hand and finger injury DDX}}


==Diagnosis==
==Evaluation==
*Clinical diagnosis
*Clinical diagnosis
*Evaluate percentage of nail bed involved, test extensor/flexor tendons and distal cap refill


==Management==
==Management==
===Simple===
===Simple===
#Trephination
[[File:Post trephonation.jpg|thumb|All blood has been expelled through the trephination hole]]
#*Handheld cautery works best - no anesthesia is required
*Trephination
#*Alternatively a needle spun in a drilling fashion
*#Cleanse with povidone-iodine solution (not flammable alcohol)
#*Sharp object (i.e. safety pin) heated with flame in an austere environment  
*#Handheld cautery works best - no anesthesia is required
#If a fracture is present, the digit should be splinted
*#Alternatively a needle spun in a drilling fashion
#Instruct pts to soak affected finger in warm water BID-TID x7d
*#Sharp object (i.e. safety pin) heated with flame in an austere environment  
*Indicated for acute sublingual hematomas (less than 24 to 48 hours old)
*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 <ref name="Incision and Drainage">Holtzman L. Incision and Drainage. In: Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, PA: Elsevier; 2014. </ref>


===Complex===
===Complex===
#Nail removal only recommended if there is associated [[nail avulsion]] or nail fold disruption<ref>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</ref>
*Nail removal only recommended if there is associated [[nail avulsion]] or nail fold disruption<ref>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</ref>
#Repair [[nailbed laceration]] using absorbable sutures
*Repair [[nailbed laceration]] using absorbable sutures
 
===Contraindications===
*Electrocautery
**Presence of acrylic nails secondry to fire risk. Remove acrylic nails before using electrocautery tool.


==Disposition==
==Disposition==
*Outpatient
*Discharge


==See Also==
==See Also==
*[[Radiograph-Negative Hand and Finger Injuries]]
*[[Hand and finger diagnoses]]
*[[Nailbed laceration]]
*[[Nailbed laceration]]


==References==
==References==
<references/>
<references/>
[[Category:Orthopedics]]
[[Category:Orthopedics]]
[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 07:41, 14 April 2019

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]
  • Atraumatic subungual hematoma may be caused by melanoma or Kaposi's sarcoma

Types

Subungal hematoma
  1. Simple: No nailbed dislocation or evidence of open fracture
  2. Complex: Aassociated with fracture or nail plate disruption

Nailtip Anatomy

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.
  • The perinychium includes the nail, the nailbed, and the surrounding tissue.
  • The paronychia is the lateral nail folds
  • The hyponychium is the palmar surface skin distal to the nail.
  • The lunula is that white semi-moon shaped proximal portion of the nail.
  • The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
  • The germinal portion is proximal to the matrix and is responsible for nail growth.

Clinical Features

  • Blood trapped under nail

Differential Diagnosis

Distal Finger (Including Nail) Injury

Hand and finger injuries

Evaluation

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

Management

Simple

All blood has been expelled through the trephination hole
  • 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
  • Indicated for acute sublingual hematomas (less than 24 to 48 hours old)
  • 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

Contraindications

  • Electrocautery
    • Presence of acrylic nails secondry to fire risk. Remove acrylic nails before using electrocautery tool.

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
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