Management of Subungual Hematoma That Stops Nail Growth
For a subungual hematoma that has stopped nail growth, the most effective management approach is immediate evacuation of the hematoma followed by appropriate nail care and possible surgical intervention if nail matrix damage is present.
Initial Assessment and Evacuation
- Determine the extent of the hematoma and its effect on the nail matrix, as this is crucial for determining the appropriate intervention
- Evacuate the hematoma promptly to relieve pressure and pain, which can be accomplished through several techniques:
- Nail trephination using electrocautery is effective, precise, and minimizes risk to the nail bed 1, 2
- An extra-fine 29-gauge insulin syringe needle can be used as an excellent alternative, particularly for smaller hematomas of the second, third, and fourth toenails where trephination may be more difficult 3
- Controlled nail trephination with specialized drills can penetrate the nail plate without damaging the nail bed 4
Post-Evacuation Management
- Elevate the affected foot to reduce swelling 5
- Apply cold compresses intermittently for the first 24-48 hours to reduce inflammation 5
- Administer appropriate analgesics for pain control 5
- Implement warm soaks with antiseptic solution 2-3 times daily to prevent infection 5
Management of Nail Matrix Damage
- When nail growth has stopped, this indicates potential damage to the nail matrix, which requires more aggressive intervention:
- Assess for nail matrix damage, which may require partial or complete nail removal to visualize the matrix
- If the nail matrix is damaged, mechanical intervention may be necessary to remove any dermatophytomas or damaged tissue within the nail plate or nail bed 6
- For severe cases with matrix damage, surgical intervention may be required to promote proper regrowth
Follow-up Care
- Regular follow-up every 2-4 weeks until resolution 5
- Monitor for complications including:
- Permanent nail deformity
- Secondary infection
- Permanent onycholysis
- Recurrent hematoma
- Return within 48-72 hours if signs of infection develop 5
Special Considerations
- For diabetic patients: More vigilant monitoring and earlier intervention due to increased infection risk 5
- For immunocompromised patients: Lower threshold for oral antibiotics and more aggressive treatment 5
Prevention of Recurrence
- Proper footwear with adequate toe box width 5
- Avoid high heels and pointed shoes 5
- Keep nails trimmed straight across 5
- Apply daily topical emollients to cuticles and periungual tissues 5
When to Consider Surgical Referral
- If the nail fails to regrow after evacuation and appropriate care
- If there is evidence of significant nail matrix damage
- If there is persistent pain or recurrent hematoma formation
- If there are signs of infection not responding to conservative management
The key to successful management is prompt evacuation of the hematoma to relieve pressure on the nail matrix, followed by appropriate care to promote healing and nail regrowth. Failure of nail regrowth after proper evacuation suggests nail matrix damage that may require surgical intervention.