Treatment of Subungual Hematoma
Nail trephination is the definitive treatment for subungual hematoma, providing immediate pain relief without requiring nail removal, suturing, or antibiotics, regardless of hematoma size or presence of underlying fracture. 1
Primary Treatment: Nail Trephination
The standard approach involves creating a hole through the nail plate to drain accumulated blood and relieve pressure 1, 2:
Technique Options
- Electrocautery (preferred method): Use hand-held cautery with a fine tip to burn a precise, small hole through the nail plate—this is cost-effective, painless, and allows accurate control 3
- Extra-fine needle technique: Insert a 29-gauge insulin syringe needle very close to the nail plate, draining blood from the hyponychium—particularly effective for smaller hematomas of the 2nd, 3rd, and 4th toenails where trephination is more difficult 4
- Controlled drill trephination: Use a uniquely designed drill that penetrates the nail plate without breaching the nail bed 2
Clinical Outcomes
Prospective data from 48 patients with 47 subungual hematomas followed for an average of 10.3 months demonstrated 1:
- 100% immediate pain relief after trephination
- Zero infectious complications (no infections, osteomyelitis, or major nail deformities)
- No complications regardless of hematoma size or presence of distal phalangeal fracture
- Average nail regrowth time of 4.0 months
What NOT to Do
Nail removal with suture repair of the nail bed is unnecessary for simple subungual hematomas, even when large or associated with fracture 1. This outdated approach causes unnecessary morbidity, delays nail regrowth, and increases risk of secondary nail dystrophy 3.
Important Caveat
While needle aspiration works for subungual hematomas, avoid needle aspiration of hematomas in other anatomic locations due to risk of introducing skin flora and subsequent infection 5. This distinction is critical—the subungual space is a unique anatomic location where drainage is both safe and necessary.
When to Consider Alternative Diagnosis
If the lesion shows ulceration, bleeding, nodular features, or longitudinal melanonychia, consider subungual melanoma rather than simple hematoma 6, 7. In such cases, the nail plate must be sufficiently removed to expose the underlying lesion, and the nail matrix must be sampled by a practitioner skilled in nail apparatus biopsy 7.