What is the appropriate treatment for a 1.5-year-old child with a subungual hematoma of the great toe caused by a heavy object, who is bearing weight without difficulty and has no other injuries?

Treatment of Subungual Hematoma in a 1.5-Year-Old Child

Perform nail trephination (drainage) immediately to relieve pain, regardless of hematoma size, and obtain a radiograph to rule out distal phalangeal fracture.

Immediate Management

Pain Relief Through Trephination

• Nail trephination should be performed promptly to decompress the hematoma and provide immediate pain relief 1, 2
• The procedure can be done using electrocautery, which is precise, cost-effective, and painless due to the high temperature creating a small hole without stimulating pain receptors 3
• Alternative methods include using an extra-fine 29-gauge insulin syringe needle inserted close to the nail plate to drain blood from the hyponychium, which is particularly well-tolerated 4
• All patients report immediate pain relief following successful drainage 1

Radiographic Evaluation

• Radiographs must be obtained because of the high incidence of associated distal phalangeal fractures with subungual hematomas 2
• The presence or absence of fracture does not change the trephination approach, as no complications occur regardless of fracture status 1

Key Treatment Principles

No Nail Removal Required

• Nail trephination alone is sufficient treatment; nail removal with suture repair of the nail bed is unnecessary regardless of hematoma size 1
• A prospective study of 47 subungual hematomas treated with trephination alone showed no complications of infection, osteomyelitis, or major nail deformities over an average 10-month follow-up period 1
• This approach avoids unnecessary trauma to the nail bed and matrix 3

Expected Recovery Timeline

• The nail typically regrows within 4.0 ± 2.6 months following trephination 1
• Parents should be counseled that possible complications include onycholysis (nail separation), transient or permanent nail deformity, and infection, though these are rare with proper treatment 2

Clinical Pitfalls to Avoid

• Do not delay trephination based on hematoma size—prompt decompression significantly reduces pain and prevents further damage to the nail bed and matrix regardless of the percentage of nail involved 2
• Do not skip radiographic evaluation—the high association with distal phalangeal fractures necessitates imaging even when the child is bearing weight comfortably 2
• Do not perform unnecessary nail removal—this outdated approach increases complications without improving outcomes 1