Subungual Hematoma Management
A subungual hematoma of the index finger from blunt trauma is not an emergency and can safely wait until tomorrow for treatment, provided there are no signs of open fracture, severe crush injury, or compartment syndrome.
Immediate Assessment at Home
The patient or family should evaluate for the following red flags that would require immediate emergency care:
- Severe, unrelenting pain despite elevation and ice application 1
- Visible bone or open wound through the nail or fingertip 1
- Numbness or inability to move the finger, suggesting nerve or tendon injury 1
- Pale or dusky fingertip distal to the injury, indicating vascular compromise 1
- Gross deformity suggesting underlying fracture 1
When Outpatient Management is Appropriate
If none of the above red flags are present, the injury can be managed on an outpatient basis the following day. Subungual hematomas are typically caused by crush injuries such as closing a finger in a door and represent a collection of blood beneath the nail plate 1.
Treatment Options Available Tomorrow
When the patient presents for care, several treatment options exist:
- Trephination with a hollow-tip needle is a simple, well-tolerated technique that can drain the blood and relieve pressure 2
- Extra-fine insulin syringe needle (29-gauge) inserted close to the nail plate is particularly effective for smaller hematomas and minimizes pain 2
- Controlled nail trephination with a specialized drill can penetrate the nail plate without breaching the nail bed, providing substantial pain relief 3
- Electrocautery trephination is effective but should be avoided if the patient has acrylic nails due to a 41.5% ignition risk 4
Home Care Until Tomorrow
While waiting for definitive treatment:
- Elevate the hand above heart level to reduce throbbing 1
- Apply ice wrapped in a towel for 15-20 minutes at a time 1
- Take over-the-counter pain medication as needed 1
Common Pitfall to Avoid
Do not assume that all subungual hematomas require immediate emergency department evaluation. The guidelines for hemorrhagic shock and major trauma 5 apply to life-threatening torso, chest, and abdominal injuries with hemodynamic instability—not to isolated finger injuries with intact skin and normal perfusion 6, 7. A simple subungual hematoma without the red flags listed above represents a minor injury that can be managed electively.