Procedure Note for Left Thumb Nail Trephination
PROCEDURE: Nail Trephination for Subungual Hematoma, Left Thumb
INDICATION: Traumatic subungual hematoma of the left thumb secondary to crush injury (weight dropped on thumb) with associated pain.
PRE-PROCEDURE ASSESSMENT:
- X-ray ordered to evaluate for distal phalanx fracture
- Nail margin and nail plate intact
- No signs of infection or nail avulsion
PROCEDURE DETAILS:
- Technique: Needle trephination
- Instrument: 18-gauge needle
- Anesthesia: None required (trephination is minimally painful)
- Number of holes: 2 small trephination holes created through nail plate
- Drainage: Dark blood successfully expressed from subungual space
- Patient response: Immediate pain relief reported
POST-PROCEDURE:
- Hemostasis achieved
- Sterile dressing applied
- Patient tolerated procedure well without complications
DISPOSITION & FOLLOW-UP:
- Await X-ray results for fracture evaluation
- Advised to keep digit clean and dry
- Expected nail regrowth time: approximately 4 months 1
- Return precautions given for signs of infection (increasing pain, purulent drainage, erythema, fever)
- Routine follow-up not required unless complications develop
CLINICAL RATIONALE: Simple trephination is the appropriate treatment for subungual hematomas regardless of size, with excellent outcomes (85% achieve excellent/very good results) and minimal complications 1, 2. Nail removal with formal nail bed repair is unnecessary for intact nails with subungual hematoma, even with large hematomas or underlying fractures 3, 4. This approach provides immediate symptomatic relief while avoiding the 4-fold higher cost and unnecessary morbidity of operative nail bed exploration 3.
Note: If acrylic nails are present, avoid electrocautery trephination due to 41.5% ignition risk; use needle trephination instead 5.