What is the treatment for a hematoma of the fingernail?

Treatment for Fingernail Hematoma

For a subungual hematoma causing pain, immediate drainage is the primary treatment using needle trephination, which provides prompt pain relief and prevents complications. 1, 2

Immediate Management

Drainage Technique

• Perform needle trephination as the first-line intervention for painful subungual hematomas 1, 2
• Use an extra-fine 29-gauge insulin syringe needle inserted very close to the nail plate to minimize pain 1
• Alternatively, use an 18-gauge needle after local anesthetic block for larger hematomas 2
• Insert the needle through the nail plate directly over the hematoma to drain the blood collection 1, 2
• Avoid using heated paper clips, as this can sear the underlying fluid and plug the drainage hole 2

When to Remove the Nail

• Remove the nail plate if there is an associated nail bed laceration requiring repair 3, 4
• If the proximal portion of the nail is free-floating after avulsion, remove it to prevent irritation and to visualize underlying pathology 2
• Nail removal is necessary when the hematoma is associated with significant nail bed injury that needs direct visualization and repair 3

Assessment for Associated Injuries

Critical Evaluation Points

• Examine for nail bed lacerations (simple, stellate, or avulsion patterns) that may be hidden beneath the hematoma 3
• Check for fractures of the distal phalanx, which commonly accompany nail bed injuries 3
• Assess the mechanism of injury to determine contamination risk and tissue loss 4
• Evaluate whether the hematoma involves more than 50% of the nail bed, which may indicate underlying nail bed laceration requiring exploration 3

Nail Bed Repair (If Indicated)

Surgical Approach

• Perform repair under magnification for optimal results 3
• Remove the nail plate completely to access the nail bed 4
• Suture any nail bed lacerations with fine absorbable sutures 4
• Replace any free segments of nail bed as a free graft 4
• Replace the nail plate as a splint after repair, or use a substitute material 3, 4

Conservative Management for Small Hematomas

Non-Drainage Approach

• Small hematomas (less than 25% of nail bed) without significant pain may be observed without drainage 3
• The hematoma will gradually resolve as the nail grows out over several weeks 5
• Monitor for signs of infection or increasing pain that would necessitate intervention 3

Follow-Up Considerations

Monitoring

• Reassess within 48-72 hours for signs of infection or reaccumulation 3
• Watch for nail deformities as the nail regrows, which may indicate inadequate initial treatment of nail bed injury 3
• Delayed secondary procedures are possible for nail sequelae, though results are unpredictable 3

Common Pitfalls to Avoid

• Do not use heated instruments for trephination, as they can seal the drainage hole and fail to provide adequate relief 2
• Do not leave free-floating nail segments in place, as they hide pathology and cause irritation 2
• Do not assume a simple hematoma when the injury mechanism suggests significant trauma—always assess for underlying nail bed laceration or fracture 3, 4
• In children, be particularly conservative and emphasize preservation of digital length 4