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December 16, 2014 by dailybolusoflr

bY: amanda crichlow, MD
What is it?
A hematoma under the nail

How does it happen?
Develops from a nailbed laceration that develops from direct trauma to the finger or toe e.g. from a hammer or getting caught in a door
How does it present?
Patient presents with pain and a hematoma under the nail. It can be complicated by involvement of the nail margins, cuticle or distal phalanx fracture (tuft fracture).
How is it diagnosed?
Clinical diagnosis – it’s obvious when you look at the nail
Rule out underlying fracture with an xray
How is it managed?
A simple subungual hematoma, even in the presence of a closed distal phalanx fracture, in which the nail is firmly adherent to the nailbed and there is minimal disruption of the surrounding tissue i.e. the nail margins and nail is intact, is NOT an indication for nail removal.
If the hematoma is greater than ½ the intact nail or smaller and painful, nail trephination is indicated.
Nail Trephination Procedure Description (with an 18 gauge needle)

This is a STERILE procedure
Provide anesthesia
Clean nail with chloroprep
Place nail in sterile field
Take 18 gauge needle and hold between your thumb and index finger
Apply gentle pressure to nail while slowly rotating the needle in a corkscrew motion through the nail
Procedure is complete when blood begins to drain from hole made with needle
A second hole may be required to ensure adequate drainage
When hematoma is drained, irrigate and clean nail and then cover with dry dressing
If fracture is present, the digit should be splinted
You can also watch the procedure:

What is the prognosis?
Normal appearing nail is usually the final result however some patients will lose their nail
What are the discharge instructions for the patient?
Keep the digit dry for 2 days.
If fracture present, patient should follow-up in hand surgery clinic
Oral antibiotics not necessary
For a tutorial video:
AccessEmergencyMedicine (via Welch library) 5 minute subungual hematoma tutorial available under multimedia
Roberts and Hedges: Clinical Procedures in Emergency medicine, 6th Edition. Philadelphia:Saunders Elsevier, 2014

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