Initial Management of Subungual Hematoma in Healthy Adults
Perform immediate nail trephination (drainage) for symptomatic subungual hematomas to relieve pain, regardless of hematoma size or presence of underlying distal phalanx fracture. 1
Immediate Assessment
Before drainage, quickly evaluate for:
- Melanoma exclusion: Confirm the lesion is truly acute traumatic blood collection (dark red, purple, or black discoloration following recent trauma) rather than melanonychia or subungual melanoma, which presents with different history and progressive pigmentation 2, 3
- Trauma history: Document mechanism and timing of injury 1
- Pain level: Trephination provides immediate pain relief in symptomatic cases 1, 4
Do not obtain routine radiographs or delay treatment—the presence of distal phalanx fracture does NOT contraindicate trephination and does not require nail removal or nail bed repair. 1
Trephination Technique Selection
First-Line Method: Electrocautery (Preferred)
Use hand-held electrocautery as the primary drainage method because it is cost-effective, precise, painless, and allows controlled penetration through the nail plate without breaching the nail bed. 4, 5
Technique specifics:
- Apply the fine-tip cautery perpendicular to the nail plate directly over the hematoma 4
- The high temperature creates a small, precise hole that immediately releases accumulated blood 4
- Patients report immediate pain relief following drainage 1, 4
Critical contraindication: Do NOT use electrocautery if acrylic nails are present—ignition occurs in 41.5% of cases, creating burn risk. 6 Remove acrylic nails first or use alternative method.
Alternative Method: Fine-Gauge Needle
Use a 29-gauge insulin syringe needle for smaller hematomas, particularly on second, third, and fourth toenails where trephination is technically more difficult. 7
Technique specifics:
- Insert the needle very close to the nail plate to minimize pain 7
- Drain blood from the hyponychium under the nail plate 7
- This method is fast, simple, and well-tolerated 7
Alternative Method: Controlled Drill Device
Specialized drill devices that penetrate the nail plate without breaching the nail bed provide quick drainage with minimal discomfort and risk. 5
What NOT to Do
Never perform nail removal with nail bed suture repair—this is unnecessary regardless of hematoma size or presence of fracture, and increases risk of nail dystrophy and delays regrowth. 1
Avoid traditional heated paper clip methods when electrocautery or fine needles are available, as these provide less control. 4, 5
Post-Procedure Management
- No antibiotics are needed—infection and osteomyelitis do not occur following simple trephination 1
- Inform patients the damaged nail will grow out and be replaced over approximately 6 months for fingernails and 12 months for toenails 2
- No specific wound care or follow-up is required for uncomplicated cases 1
Common Pitfalls
- Delaying treatment for radiographs: Fracture presence does not change management—trephinate immediately for symptomatic relief 1
- Removing the nail unnecessarily: This outdated practice causes secondary dystrophy from matrix pressure and delays regrowth 4, 1
- Using electrocautery with acrylic nails: This causes ignition in nearly half of cases 6
- Misdiagnosing melanoma as hematoma: Always confirm acute trauma history; subungual melanoma requires biopsy by practitioners skilled in nail apparatus procedures 3, 8