What is the treatment for bleeding under a toenail?

Treatment of Bleeding Under a Toenail (Subungual Hematoma)

For a simple subungual hematoma causing pain, perform nail trephination (drilling through the nail plate) to drain the blood—this provides immediate pain relief and does not require nail removal, antibiotics, or nail bed repair regardless of hematoma size. 1, 2

Immediate Management

Trephination Technique

• Perform nail trephination using electrocautery, a heated paperclip, or a specialized drill to create a hole through the nail plate 1, 2
• Insert the instrument perpendicular to the nail plate directly over the hematoma to allow blood drainage 1
• For smaller hematomas (especially on 2nd-4th toes), an alternative technique uses a 29-gauge insulin syringe needle inserted close to the nail plate at the hyponychium to drain blood with minimal pain 3
• The controlled drill technique penetrates the nail plate without breaching the nail bed, minimizing discomfort and risk 1

Expected Outcomes

• Patients report substantial pain relief within 8 hours of drainage 1
• Average time for complete nail regrowth is 4.0 ± 2.6 months 2
• No complications of infection, osteomyelitis, or major nail deformities occur with trephination alone 2

When Nail Removal and Exploration ARE Required

Do NOT perform simple trephination if any of these conditions exist: 4

• The nail plate itself is lacerated or avulsed 4
• A proximal fracture involves the germinal matrix 4
• A distal phalanx fracture requires stabilization 4
• There is fragmentation or avulsion of the nail bed 4

In these cases, nail plate removal with formal nail bed exploration and repair is indicated 4

Pre-Procedure Assessment

Perform these specific evaluations before treatment: 4

• Neurovascular examination: Check pulp capillary refill, perform 2-point discrimination, and compare with an uninjured digit 4
• Range of motion assessment of the affected digit 4
• Radiographs to detect distal phalangeal fractures 2
• Consider local anesthesia and tourniquet application for adequate clinical evaluation 4

Critical Evidence Point

A prospective study of 48 patients with 47 subungual hematomas followed for an average of 10.3 months demonstrated that nail trephination alone is sufficient regardless of hematoma size or presence of distal phalanx fracture—nail removal with suture repair of the nail bed is unnecessary for simple subungual hematomas 2. This contradicts older teaching that large hematomas (>50% nail area) require nail removal.

Common Pitfalls to Avoid

• Do not remove the nail plate for simple subungual hematomas, even if the hematoma is large or a non-displaced distal phalanx fracture is present 2
• Do not prescribe prophylactic antibiotics for simple subungual hematomas treated with trephination 2
• Do not delay trephination—perform it promptly while the hematoma is still liquid to achieve effective drainage 1, 2