Management of Subungual Hematoma
The most effective treatment for subungual hematoma is nail trephination (creating a small hole in the nail plate) to drain the accumulated blood, which provides immediate pain relief and prevents complications. 1
Initial Assessment
- Subungual hematomas typically result from crush injuries (such as shutting a finger in a door) or repetitive trauma in athletes like runners and dancers 2
- Evaluate the extent of the hematoma and assess for signs of nail bed laceration or distal phalanx fracture that might require additional treatment 1
Treatment Options
Nail Trephination (First-Line Treatment)
- Nail trephination alone is sufficient for most subungual hematomas regardless of size, with no complications of infection, osteomyelitis, or major nail deformities reported in follow-up studies 1
- Several effective methods for nail trephination include:
- Electrocautery/Hand-held cautery: A cost-effective, precise method that creates a small hole in the nail plate with minimal discomfort due to the high temperature and fine tip 3
- Controlled nail trephination: Using a specially designed drill that penetrates the nail plate without damaging the nail bed 4
- Extra-fine insulin syringe needle (29-gauge): Particularly useful for smaller hematomas of the second, third, and fourth toenails where traditional trephining is more difficult 5
Management of Severe Cases
- For severe and/or painful lesions, or when associated with a pressure hematoma or subungual abscess, it may be necessary to remove the nail plate 6
- The nail bed must be cleaned and cultured at the same time, and any infection should be promptly treated with appropriate topical/oral antibiotics and antiseptics 6
- The nails should be cut regularly until the nail plate grows reattached 6
Post-Procedure Care
- After drainage, most patients report immediate relief of pain 1
- Monitor for signs of infection, though complications are rare when proper technique is used 1
- The average time for the nail to grow back completely is approximately 4 months 1
Special Considerations
- Nail removal with suture repair of the nail bed is unnecessary for simple subungual hematomas, regardless of size 1
- For patients with underlying coagulation disorders or those on anticoagulant therapy, consider the risks and benefits before proceeding with any invasive procedure 7
- If infection is suspected after drainage, obtain bacterial/viral/fungal cultures and begin oral antibiotics with anti-Staphylococcus aureus and gram-positive coverage 6
Prevention of Recurrence
- For patients at risk of recurrent trauma (e.g., athletes), recommend:
By following these guidelines, most subungual hematomas can be effectively managed with minimal discomfort and excellent outcomes.