II. Pathophysiology
- Bleeding develops between nail and phalanx
- Typically caused by crush injury to the nail and distal fingertip
III. Symptoms
- Severe, throbbing digital pain
IV. Signs
- Discoloration of nail
- Tip of digit swollen and tender
V. Associated conditions
- Nail Bed Laceration
- Distal Tuft Fracture
VI. Imaging
- XRay AP, lateral and Oblique XRay of digit
- Indicated for Subungual Hematoma involving >50% of the nail bed
- Assess for distal Tuft Fracture
VII. Management: Drainage (Nail Trephination)
- Contraindications
- Phalanx Fracture
- Nail Bed Laceration
- Large Subungual Hematomas (>50% of nail)
- Previously recommended to suture Nail Bed Laceration in large Hematomas
- However, in practice, reasonable to leave nail in place, and trephinate large Subungual Hematomas
- Technique
- Precaution
- Avoid lunula (and underlying nail matrix)
- Gently drill 2-3 small holes into nail
- Number 11 blade or
- Spin 18 gauge needle between fingers or
- Heated paper clip
- Splint fingertip (e.g. AlumaFoam Splint)
- Apply for up to 3 days until pain subsides
- Precaution
VIII. Management: Large Subungual Hematoma (>50%)
- See Nail Bed Laceration
- Standard teaching is to remove nail, repair Nail Bed Laceration, and replace nail
- Study demonstrated no benefit in children to nail bed repair over trephination in large Subungual Hematoma
IX. References
- Brandenburg (1996) Consultant p.331-340
- Calmbach (1996) Lecture in Minneapolis
- Dvorak (1996) Lecture in Minneapolis
- Lillegard (1996) Lecture in Minneapolis
- Lin, Gajendran and Orman in Herbert (2016) EM:Rap 16(11): 7-8
- Wang (2001) Am Fam Physician 63(10):1961-66 [PubMed]