What is the treatment for a subungal hematoma?

Treatment of Subungual Hematoma

For painful subungual hematomas, nail trephination (drilling a hole through the nail plate to drain blood) is the definitive treatment and provides immediate pain relief without requiring nail removal, regardless of hematoma size or presence of distal phalanx fracture. 1

Immediate Management

Trephination Technique Options

• Electrocautery method: Use a heated cautery device to create a hole through the nail plate, which is the most commonly employed technique and provides rapid drainage 1
• Extra-fine needle drainage: Insert a 29-gauge insulin syringe needle close to the nail plate near the hyponychium to evacuate blood—this is particularly effective for smaller hematomas of the second, third, and fourth toenails where traditional trephination is more difficult 2
• Controlled drill trephination: Use a specially designed drill that penetrates the nail plate without breaching the nail bed, providing quick drainage with minimal discomfort 3

Key Technical Points

• Perform trephination as soon as possible after injury to maximize pain relief 1
• The procedure provides substantial or complete pain relief immediately after drainage 3, 4, 1
• Nail removal with suture repair of the nail bed is unnecessary, even for large hematomas or those associated with distal phalanx fractures 1

Pre-Procedure Evaluation

• Obtain radiographs of the affected digit to detect distal phalangeal fractures, which are commonly associated with subungual hematomas 1, 5
• Measure hematoma size for documentation purposes 1
• For patients on anticoagulant therapy or with coagulation disorders, consider risks versus benefits before proceeding with trephination 6

Severe Cases Requiring Nail Removal

• Reserve nail plate removal only for severe/painful lesions associated with pressure hematoma or subungual abscess 6
• When removing the nail, clean and culture the nail bed, treating any infection with appropriate topical or oral antibiotics and antiseptics 6

Expected Outcomes and Follow-Up

• Average time for nail regrowth is 4.0 ± 2.6 months 1
• Complications are rare when simple trephination is performed 1
• Possible complications include onycholysis, transient or permanent nail deformity, and infection, though these occur infrequently with proper technique 5
• Follow-up at 2 weeks to assess healing and monitor for complications 4

Prevention Strategies

• Athletes and those at risk for recurrent trauma should use properly fitted footwear and regularly trim nails to prevent nail edge trauma 6
• Use protective equipment during activities posing crush injury risk 6

Common Pitfalls to Avoid

• Do not routinely remove the nail and suture the nail bed—this outdated approach is unnecessary and increases morbidity 1
• Do not delay trephination, as prompt decompression significantly reduces pain and prevents further damage to the nail bed and matrix 5
• Do not skip radiographic evaluation, as distal phalanx fractures are frequently present and may require additional management 1, 5