From the Research
The initial management for a patient presenting with a subungual hematoma involves pain relief and evacuation of the trapped blood, with trephination (nail decompression) recommended for painful hematomas involving more than 25-50% of the nail bed, as supported by the most recent study 1. The procedure can be done using a heated paperclip, electrocautery device, or a sterile 18-gauge needle to create a small hole in the nail plate to release the trapped blood. Prior to the procedure, clean the nail with antiseptic solution and consider digital nerve block with 1% lidocaine (without epinephrine) for pain control. After drainage, apply antibiotic ointment and a sterile dressing. The procedure provides immediate pain relief by reducing pressure under the nail. Some key points to consider in the management of subungual hematoma include:
- For small, minimally painful hematomas (less than 25% of nail bed), conservative management with pain control using acetaminophen or NSAIDs may be sufficient 2.
- X-rays should be considered if there is concern for underlying fracture, especially with crush injuries.
- Patients should be advised to keep the area clean, elevated, and to watch for signs of infection such as increasing pain, redness, or purulent drainage. It is also important to note that the management of subungual hematoma has been discussed in various studies, including a systematic review 2 and a study on dermoscopic diagnosis 3, but the most recent study 1 provides the most up-to-date guidance on the initial management of this condition.