What is the management for a nail hematoma?

Management of Nail Hematoma

For nail hematomas, immediate trephination (drilling a hole through the nail plate) is the recommended treatment to relieve pain and prevent complications by draining the accumulated blood.

Assessment and Diagnosis

• Nail hematomas (subungual hematomas) present as dark red or purple collections of blood under the nail plate
• Typically result from trauma (crush injuries, direct blows to the nail)
• Main symptoms include throbbing pain due to pressure from trapped blood
• Assessment should focus on:
  • Size of hematoma (percentage of nail involved)
  • Time since injury
  • Associated nail or digit injuries
  • Presence of fracture (consider X-ray for severe injuries)

Treatment Algorithm

Immediate Management

1. Small to large hematomas with pain:

   • Trephination (nail drilling) is the primary treatment 1
   • Should be performed within hours of injury for maximum pain relief
   • No need for nail removal regardless of hematoma size 1

2. Trephination techniques (in order of preference):

   • Hand-held electrocautery device (most precise and painless) 2
   • Controlled nail drill with depth limitation 3
   • Extra-fine 29-gauge insulin needle (particularly useful for smaller toenails) 4
   • Paper clip heated with flame (if other tools unavailable)

3. Trephination procedure:

   • Clean the nail with antiseptic solution
   • Create 1-2 small holes through the nail plate without penetrating the nail bed
   • Apply gentle pressure to facilitate drainage
   • Topical hemostatic agents like aluminum chloride or ferric subsulfate solution are preferred over electrocautery for post-procedure bleeding control 5

Special Considerations

• For hematomas with nail disruption or laceration:

  • If nail is partially avulsed, consider nail bed repair
  • If nail plate is intact but hematoma is painful, proceed with trephination

• For hematomas associated with taxane chemotherapy:

  • If painful hematoma is present, partial or total nail avulsion may be required 5
  • Obtain bacterial/fungal cultures if infection is suspected
  • Begin oral antibiotics with anti-staphylococcus coverage if infection present

Post-Procedure Care

• Keep the area clean and dry
• Apply topical antibiotic ointment
• Monitor for signs of infection (increasing pain, redness, swelling)
• Nail regrowth typically takes 4-6 months 1
• No major nail deformities should occur with proper trephination 1

Complications to Watch For

• Secondary infection
• Persistent pain after drainage (may indicate underlying fracture)
• Nail dystrophy (rare with proper technique)

Prevention of Recurrence

• For patients on taxane chemotherapy with recurrent hematomas:
  • Consider preventive measures including topical emollients on nail folds
  • Protective nail lacquers to limit water loss
  • Cotton gloves for protection 5
  • Frozen gloves/socks during chemotherapy administration 5

Nail trephination provides immediate pain relief with minimal risk of complications when performed correctly, making it the treatment of choice for painful subungual hematomas 6, 1.