Is the current management plan for a subungual hematoma, including foot baths with Epsom salt and scheduled toenail removal, adequate?

Management of Subungual Hematoma

Nail trephination alone is the recommended treatment for subungual hematoma, and scheduled toenail removal is unnecessary. 1

Assessment of Subungual Hematoma

Subungual hematoma is a collection of blood beneath the nail plate, typically caused by:

• Crush injuries (shutting a finger/toe in a door)
• Repetitive trauma (common in runners and dancers) 2
• Direct trauma to the nail

Clinical presentation includes:

• Pain due to pressure from accumulated blood
• Discoloration of the nail (black, purple, or red)
• Potential nail deformity if left untreated

Recommended Treatment Approach

First-line Treatment: Nail Trephination

Nail trephination (creating a small hole in the nail to release trapped blood) is the definitive treatment for subungual hematoma. This procedure:

• Provides immediate pain relief
• Prevents nail dystrophy from pressure on the matrix
• Avoids complications associated with complete nail removal 1

Trephination Methods (in order of preference):

1. Electrocautery: Cost-effective and precise method that creates a small hole in the nail plate with minimal discomfort 3

2. Fine-gauge needle technique: Using a 29-gauge insulin syringe needle inserted close to the nail plate, particularly useful for smaller hematomas of the second, third, and fourth toenails 4

3. Manual trephination: Using a sterile paperclip or specialized trephination device

Post-Procedure Care

• Keep the area clean and dry
• Apply topical antibiotic ointment if needed
• Monitor for signs of infection
• Regular follow-up to assess nail regrowth

Important Considerations

• Complete nail removal is unnecessary for simple subungual hematomas, regardless of size or presence of fracture 1
• Prospective studies show no complications of infection, osteomyelitis, or major nail deformities when treated with nail trephination alone 1
• The average time for nail regrowth after trephination is approximately 4 months 1

When to Consider Alternative Management

• Presence of significant nail bed laceration
• Grossly displaced fracture of the distal phalanx
• Signs of infection
• Chronic or recurrent hematomas

Conclusion on Current Management Plan

The current management plan of Epsom salt foot baths followed by scheduled toenail removal is not supported by evidence. Epsom salt soaks alone will not adequately relieve the pressure from the hematoma, and complete toenail removal is unnecessarily aggressive for a simple subungual hematoma.

Instead, immediate trephination to drain the hematoma would provide prompt pain relief and better outcomes with less invasive intervention.