Subungual Hematoma

By admin On Mar 9, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Subungual Hematoma

Subungual Hematoma

Scott Berkenblit MD, PhD

Dawn M. LaPorte MD

Basics

Description

Subungual hematoma is a localized
collection of blood between the nail and nail bed of a finger or toe
that results from an injury or laceration of the soft tissue of the
nail bed under an intact nail.
Pressure of the hematoma against the periosteum of the distal phalanx produces severe pain.
Classification of the injury to the underlying nail bed tissue:
- Simple laceration
- Stellate laceration
- Crush injury

Epidemiology

Older children and young adults are the most commonly affected individuals.
One of the most common hand injuries seen in the office or emergency room
The long finger is most frequently injured of all of the digits because of its prominence.

Etiology

Blunt trauma to the distal phalanx causes this condition.
Injury in a door is the most common mechanism, followed by smashing between 2 objects and injury by a saw.

Associated Conditions

Distal phalanx fracture

Diagnosis

Signs and Symptoms

Typically, in an acute injury, the patient complains of localized pain and gives a history of trauma to the finger or toe.
Nail deformity is a late sign of a neglected nail bed injury.

Physical Exam

On inspection, the hematoma is visible through the nail.
If an underlying fracture of the distal phalanx is present, diffuse swelling of the digit tip is seen.

Tests

Imaging

Plain films of the affected digit should be obtained to rule out an associated fracture of the distal phalanx.

Differential Diagnosis

Contusion or fracture of the distal phalanx without hematoma formation
Subungual melanoma, if history of injury is not clear
Pyogenic granuloma at base of the nail, usually caused by perforation with cuticle scissors

Fig. 1. A subungual hematoma may be decompressed with a cautery or hot needle for pain relief.

Treatment

General Measures

Treatment for a painful subungual hematoma involving <50% of the nail bed (1):
- Prepare the nail in sterile fashion before the procedure (Fig. 1).
- It is not necessary to anesthetize the finger.
- Drain the hematoma by trephining 1–3
  holes in the nail over the affected area with a battery-powered cautery
  such as an ophthalmic cautery (preferred method), a heated paper clip,
  or a 16-gauge needle, while the patient presses the pad of the finger
  firmly against a hard surface.
- Drainage provides prompt relief of pain.
Treatment for a hematoma involving >50% of the nail bed or with an underlying fracture:
- Remove the nail to inspect and repair the underlying nail bed injury.
- For an underlying fracture:
  - Splint the distal phalanx in addition to replacing the nail.
  - A displaced fracture may require reduction and fixation.

P.431

Activity

The patient may continue activity as tolerated.

Special Therapy

Physical Therapy

A hand therapist can fashion a tip protector to wear until the end of the finger is less sensitive.

Medication

Prescribe NSAIDs for pain relief.
Prophylactic antibiotics should be given.

Surgery

Surgical repair of a nail bed laceration requires nail removal.
- Use a digital nerve block to obtain adequate regional anesthesia.
- Grasp the distal edge of the nail with a clamp and bluntly dissect the nail from the nail bed and eponychium.
- After irrigation, repair the laceration with fine absorbable sutures (e.g., 6-0 or 7-0 chromic).
- Splint the eponychial fold to prevent formation of adhesions, which can result in deformity of the regrown nail.
  - Use the proximal part of the removed nail or a piece of heavy foil (suture wrapper) as a splint.
  - The replaced nail may be sutured to the eponychium with 5-0 nylon.
  - Cover the exposed nail bed with petrolatum gauze and apply a tubular gauze dressing.

Follow-up

Prognosis

The prognosis is excellent, if proper assessment and treatment are performed.

Complications

Nail deformity (i.e., fissured nail) if
the eponychial fold is not properly splinted after removal of the nail
or if a nail bed laceration is not repaired
Split or nonadherent nail
Osteomyelitis, a complication of unsterile drainage of the hematoma and improper wound dressing

Patient Monitoring

The patient should be given a follow-up appointment within 1 week if nail bed repair has been performed.

References

1. Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med 1991;9: 209–210.

Additional Reading

Batrick N, Hashemi K, Freij R. Treatment of uncomplicated subungual haematoma. Emerg Med J 2003;20:65.

Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg 1999;24A:1166–1170.

Sommer NZ, Brown RE. The perionychium. In: Green DP, Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005:389–416.

Miscellaneous

Patient Teaching

Patient should be counseled about signs of infection.

Prevention

Late deformity of the nail is difficult to reconstruct, and the results are unpredictable.
Therefore, guidelines given earlier for
inspecting and repairing nail bed injury should be followed to minimize
the risk of late deformity.

FAQ

Q: How is the pain associated with subungual hematoma addressed?

A:
The pain is secondary to the pressure of blood in this confined space,
and evacuation of the hematoma is indicated to relieve the pain. The
finger is prepped with Betadine, and a battery-powered microcautery tip
is used to burn a hole through the nail.

Q: Is nail removal and nail bed repair always indicated in subungual hematoma?

A:
Nail removal and nail bed repair are considered if >50% of the nail
is undermined by blood and the nail is broken or the nail edges are
disrupted.