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    Subungual Hematoma – Treatment

    Trauma

    Last Updated Feb 18, 2021
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    By Julian Marsden, Tanis King

    Context

    • Subungual hematomas are an accumulation of blood beneath the fingernail or toenail, usually caused by direct crushing trauma to the digit that results in bleeding of the nail bed (Figure 1).
      • Patients usually present with throbbing pain and swelling of the digit.
      • Blue-purple-black discoloration beneath the nail.
      • Nail and nail folds may be intact or may have injury (e.g. nail laceration).
    • Consider x-ray if significant pain.
    • Treatment may not be necessary if the subungual hematoma is not acutely painful for the patient and it is not accompanied by other injuries to the digit.

    Figure 1. Classic appearance of subungual hematoma

    Recommended Treatment

    Trephination

    • Trephination is preferred over nail removal for subungual hematomas that are painful and have intact nail folds.
    • Trephination puts holes in the nail plate to drain the subungual hematoma which alleviates pain and promotes healing of the nail bed. This can be achieved using:
      • Electrocautery
      • Presterilized needle
      • Bunch biopsy
    • Whichever method is used to trephinate the nail plate, penetrating too deeply to the nail bed must be avoided.
    • After trephination, the digit should be kept dry and clean and should not be soaked.

    Nail Removal

    • Removal of the nail plate is only recommended for subungual hematomas accompanied by nail bed lacerations (e.g. fingertip or toe avulsion).
    • Removal of the nail plate for nail bed exploration is not recommended for subungual hematomas with:
      • Intact nail plate and nail folds.
      • At least partial adherence of the nail plate to the nail bed.
    • It is no longer recommended to remove the nail plate when the subungual hematoma exceeds 25-50% of the nail plate surface as there is no difference in short or long-term healing outcomes between trephination and nail removal.

    Prophylactic Antibiotics

    • There is no evidence that supports the use of prophylactic antibiotics to reduce infection after trephination of subungual hematoma.
    • Subungual hematomas associated with an open fracture may require prophylactic antibiotics depending on the type of fracture and other patient factors (discussed elsewhere).

    Tetanus Prophylaxis

    • Review of tetanus immunization status should be completed for patients with subungual hematoma accompanied with a wound such as:
      • Wounds contaminated with dirt, feces, saliva
      • Puncture wounds
      • Avulsions
      • Wounds resulting from crushing, burns, foreign objects

    Other Resources

    Related Information

    Reference List

    1. Gellman H. Fingertip-bed injuries in children: Current concepts and controversies of treatment. J of Craniofac Surg. 2009;20:1033-1035.


    2. Hawken JB, Giladi AM. Primary management of nail bed and fingertip injuries in the emergency department. Hand Clin. 2021;37:1-10.


    3. Dean B, Becker G, Little C. The management of the acute traumatic subungual haematoma: a systematic review. Hand Surg. 2012;17:151-154.


    4. Batrick N, Hashemi K, Freij R. Treatment of uncomplicated subungual haematoma. Emerg Med J. 2003;20(1):65.


    5. Salter SA, Ciocon DA, Gowrishankar TR, Kimball AB. Controlled nail trephination for subungual hematoma. The American Journal of Emergency Medicine. 2006;24(7):875-877.


    6. Bonisteel PS. Practice tips. Trephining subungual hematomas. Can Fam Physician. 2008;54(5):693.


    7. Costello J, Howes M. Prophylactic antibiotics for subungual haematoma. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. Emerg Med J. 2004;21:498-503.


    8. Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. J Hand Surg Br. 2003;28(5):388.


    9. Havers FP, Moro PL, Hunter P, et al. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: Updated recommendations of the Advisory Committee on Immunization Practices – United States, 2019. MMWR Morb Mortal Wkly Rep 2020; 69:77.


    10. Nail Trauma [Image]. 2018 Dec [cited 2020 Dec 5]. In: Harvard Health Publishing [Internet]. 


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