Subungual Hematoma Treatment
The most important aspect of subungual hematoma treatment is prompt drainage via nail trephination to relieve pain and pressure, which provides immediate symptom relief without requiring nail removal or nail bed repair in the vast majority of cases. 1, 2
Primary Treatment Approach
Simple nail trephination is the definitive treatment for symptomatic subungual hematomas, regardless of hematoma size or presence of underlying fracture. 1, 2 This approach:
- Provides immediate and complete pain relief in essentially all patients 1, 3
- Results in excellent or very good outcomes in 85% of cases, with 67% reporting no residual abnormalities at long-term follow-up 2
- Requires no aggressive surgical intervention such as nail removal or nail bed repair 1, 2
Trephination Techniques
Multiple effective methods exist for drainage:
- Electrocautery is the most commonly studied technique, providing reliable penetration of the nail plate 1
- Extra-fine 29-gauge insulin syringe needle inserted close to the nail plate minimizes pain and is particularly effective for smaller hematomas of the second, third, and fourth toenails where traditional trephining is more difficult 4
- Controlled drill devices designed to penetrate the nail plate without breaching the nail bed offer quick drainage with minimal discomfort 5
When Nail Removal IS Indicated
Nail removal becomes necessary only in specific circumstances:
- Severe pain with pressure hematoma that cannot be adequately drained by trephination 6
- Presence of subungual abscess 6, 7
- Severe and/or painful lesions significantly impacting daily activities 6
Post-Trephination Management
After successful drainage:
- No routine antibiotics are required in simple subungual hematomas 1
- Average time for complete nail regrowth is 4.0 ± 2.6 months 1
- Monitor for signs of infection (increased pain, redness, swelling, purulent drainage) 7
- If infection develops, obtain cultures and initiate antibiotics with anti-staphylococcal coverage 7
Critical Evidence on Outcomes
A prospective study of 48 patients with 47 subungual hematomas treated by trephination alone demonstrated zero cases of infection, osteomyelitis, or major nail deformities over an average 10.3-month follow-up period. 1 This held true regardless of:
Common Pitfall to Avoid
The most critical error is performing unnecessary nail removal with nail bed repair, as suggested in older literature. 1 This aggressive approach:
- Is not supported by prospective outcome data 1, 2
- Subjects patients to unnecessary pain and prolonged recovery 1
- Does not improve outcomes compared to simple trephination 1, 2
Only 2% of patients experience poor outcomes (nail splitting) after simple trephination, and these cannot be predicted at presentation. 2