What is the treatment for a subungual hematoma?

Treatment of Subungual Hematoma

The treatment of choice for a subungual hematoma is controlled nail trephination to drain the accumulated blood, which provides immediate pain relief and prevents further damage to the nail bed and matrix. 1

Diagnosis and Assessment

• Subungual hematomas appear as well-circumscribed red to red-black pigmentation under the nail plate
• Caused by trauma resulting in blood collection between the nail plate and nail bed
• Extremely painful due to pressure from blood accumulation
• Radiographs should be obtained to rule out associated distal phalangeal fractures 2
• Dermoscopy can help differentiate from nail melanoma by showing:
  • Homogeneous pattern (92% of cases)
  • Globular patterns (42%)
  • Peripheral fading (54%)
  • Absence of Hutchinson sign and irregular bands 3

Treatment Options

1. Nail Trephination (First-line)

• Technique options:

  • Hand-held cautery - precise, cost-effective method that creates a small hole in the nail plate 4
  • Controlled nail drill - penetrates nail plate without damaging nail bed 1
  • Other methods: heated paperclip, electrocautery, or needle

• Procedure steps:

  1. Clean the affected area with antiseptic solution
  2. Create a small hole through the nail plate over the hematoma
  3. Apply gentle pressure to facilitate drainage
  4. No anesthesia typically required as nail plate lacks nerve endings

• Benefits:

  • Immediate pain relief
  • Prevents nail dystrophy from pressure on matrix
  • Minimizes risk of nail deformity
  • Quick procedure with minimal discomfort 1, 4

2. Complete Nail Removal

• Reserved for cases with:
  • Severe nail detachment
  • Significant pain despite trephination
  • Signs of infection
  • Subungual abscess 5

Post-Procedure Care

• Clean daily with lukewarm water and mild soap, pat dry thoroughly 5
• Apply antiseptic ointment if prescribed
• Cover with clean, dry bandage if drainage continues
• Monitor for signs of infection:
  • Increasing redness, swelling, or warmth
  • Pus or foul-smelling discharge
  • Red streaks extending from the toe
  • Fever above 101°F 5
• Limit standing and walking for the first few days to reduce swelling and pain 5

Potential Complications

• Onycholysis (separation of nail from nail bed)
• Transient or permanent nail deformity
• Secondary infection
• Nail dystrophy 2

Follow-Up Care

• Return for follow-up within 1-2 weeks to ensure proper healing
• Seek immediate medical attention if signs of infection develop 5
• Complete healing with normal nail growth may take 6-12 months for toenails

Prevention of Future Injuries

• Wear proper footwear with adequate toe box
• Avoid repeated trauma to nails
• Trim nails properly (straight across, not too short) 5

Remember that prompt treatment of subungual hematomas is essential to relieve pain and prevent complications. Most cases can be effectively managed with simple trephination techniques in an outpatient setting.