What is the recommended treatment for a patient with a subungal hematoma, considering potential complications and comorbidities such as bleeding disorders or anticoagulant medication use?

Treatment for Subungual Hematoma

For simple subungual hematomas, perform nail trephination immediately to relieve pain—this is the definitive treatment regardless of hematoma size, and nail removal with suture repair is unnecessary. 1

Immediate Assessment

Before treatment, obtain the following:

• Radiographs of the affected digit to detect distal phalangeal fracture, which occurs with high incidence in subungual hematomas 2, 1
• Measure hematoma size as part of documentation, though size does not alter treatment approach 1
• Assess for systemic causes if trauma history is absent or unclear, including medication reactions, bleeding disorders, or systemic pathology 2

Primary Treatment: Nail Trephination

Technique options (choose based on available equipment):

• Electrocautery trephination is the standard approach, providing immediate pain relief in all patients 1
• 29-gauge insulin syringe needle inserted very close to the nail plate, draining blood from the hyponychium—particularly successful for smaller hematomas of the second, third, and fourth toenails where traditional trephining is more difficult 3

Key technical points:

• Insert the drainage instrument as close to the nail plate as possible to minimize pain 3
• Perform trephination promptly to significantly reduce pain and prevent further damage to the nail bed and matrix 2
• All patients report complete pain relief after the procedure 1, 4

Special Considerations for Anticoagulated Patients

For patients on anticoagulant or antiplatelet medications:

• Do not withhold trephination based on medication status alone 5
• Assess bleeding severity using these criteria: hemodynamic instability, significant ongoing blood loss, or inability to control bleeding with local measures 5
• For non-severe bleeding: Proceed with standard trephination without reversing anticoagulation or transfusing platelets if bleeding can be controlled 5
• For severe bleeding: Consult the clinician managing anticoagulation regarding hemostatic management and potential need for reversal agents 5

Specific anticoagulation management:

• Warfarin: Consider oral or IV vitamin K only if patient requires hospitalization or transfusion 5
• DOACs (dabigatran, rivaroxaban, apixaban, edoxaban): 4-factor PCC or idarucizumab (dabigatran only) for severe bleeding 5
• Platelet inhibitors (aspirin, clopidogrel): Platelet transfusion may be ineffective depending on timing of most recent dose; antifibrinolytics and desmopressin may support hemostasis 5
• Do not give additional doses of anticoagulant or antiplatelet medication while bleeding is active 5

What NOT to Do

Avoid nail removal with suture repair of the nail bed—this is unnecessary regardless of hematoma size or presence of fracture, as no complications of infection, osteomyelitis, or major nail deformities occur with trephination alone 1

Expected Outcomes and Follow-Up

• Immediate pain relief occurs in all patients following trephination 1, 4
• Average time for nail regrowth: 4.0 ± 2.6 months 1
• Complications are rare when proper technique is used 1, 4

Warn patients about potential complications:

• Onycholysis (nail separation) 2
• Transient or permanent nail deformity 2
• Infection (rare with proper technique) 2, 1

Follow-up timing:

• Phone follow-up at 2 weeks to assess for complications 4
• Document complete resolution of pain and absence of complications 4

Common Pitfalls to Avoid

• Do not delay trephination waiting for radiographs if pain is severe—perform imaging concurrently or immediately after drainage 2
• Do not refuse treatment based on presence of distal phalangeal fracture, as this does not contraindicate trephination 1
• Do not routinely reverse anticoagulation for simple subungual hematoma unless bleeding cannot be controlled with local measures 5