Hematoma fingernail: Subungual Hematoma (Blood Under Nail): Causes, Treatments & Drainage

04.03.197506.10.2021 by alexxlab

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Subungual Hematoma (Blood Under Nail): Causes, Treatments & Drainage

Your doctor may call it a “subungual hematoma” if you have bleeding under a fingernail or toenail. It usually happens if the nail gets crushed in an injury. It can cause symptoms such as intense pain and throbbing as blood collects under the nail.

Unless you also have broken bones or damage to the nail bed and/or surrounding tissues, this injury usually isn’t worrisome.

Causes

These injuries can happen easily. You might:

Slam your finger in a car door or house door
Hit your finger with a heavy object such as a hammer
Drop a heavy object such as a dumbbell on your toe
Stub your toe on a hard surface

If you have a darkened area under a nail and haven’t had an injury, see your doctor to rule out other possible causes.

Symptoms

The most common symptom is severe, throbbing pain. It happens because of the pressure of blood collecting between the nail and the nail bed.

You may also have:

A dark-colored discoloration (red, maroon, or purple-black) under all or part of the affected nail
Tenderness and swelling of the tip of the affected finger or toe

Diagnosis

If you had a severe blow to a finger or toe, either seek immediate medical attention from your doctor or go to an emergency room. You should do this in case you have broken bones or serious damage to the nail bed and/or surrounding tissues.

Your doctor will examine your nail. You’ll probably also have an X-ray taken to see if you have a bone fracture or other injury.

Treatment

A painless and small subungual hematoma usually doesn’t need treatment. But the pressure generated by pooled blood under the nail can be extremely painful.

To relieve the pain, your doctor may perform decompression, also called trephination, which allows the underlying blood to drain, relieving pressure and pain to the area.

Your doctor may numb the affected finger or toe with a nerve block and use one of the following decompression methods:

Cautery. The doctor uses a heated wire (electrocautery device) or carbon laser to burn a hole or holes. The heated tip of the wire is cooled by contact with the hematoma, which prevents injury to the nail bed. This is a quick and painless procedure.

Needle. The doctor uses a needle to make a hole in the nail.

After the procedure, your doctor will bandage your nail. You will need to keep the finger or toe bandaged and elevated — and may also need to use cold compresses — during the first 12 hours after decompression. In some cases, your doctor may recommend you use a splint for as long as 3 days until the tenderness subsides.

The main complication associated with decompression is a small risk of infection in the residual hematoma.

If you have bleeding under a large area of the nail surface, the nail bed may be injured. In this case, your doctor may need to remove the entire nail and use stitches to repair the nail bed.

Recovery

Unless the area of bleeding is very small, an affected nail will usually fall off on its own after several weeks because the pooled blood has separated it from its bed.

A new fingernail can regrow in as little as 8 weeks. A new toenail may not fully regrow for about 6 months. If there has been injury to the nail bed and/or surrounding tissues, the new nail may take longer to grow.

Even with the best repair, there is still a possibility that the new nail may grow back and not look normal. See your doctor if you notice any problems with the nail as it heals and regrows.

Subungual Hematoma – an overview

Trephination for Subungual Hematoma

Subungual hematomas, which typically not only result after acute crush injury but can also be seen in cases of repetitive trauma (e.g., long distance runners), are caused by rupture of vessels within the nail bed. Encasement of the bleed by the nail plate results in visible collection of a hematoma that is associated with mild to severe throbbing pain. Trephination, or introduction of a surgically created hole, through the nail plate can provide immediate pain relief, as well as reduce the resultant nail discoloration.

Despite the frequency with which subungual hematomas occur, there still exists controversy regarding when trephination versus exploration of the nail bed for lacerations is indicated. Historically, hematomas greater than 50% of the total nail surface were guided to undergo repair via suturing of a nail bed laceration; this recommendation was derived from a study of 47 patients that identified repairable lacerations (>3 mm) in 60% of individuals with a hematoma spanning more than 50% of the nail plate.⁹ However, multiple subsequent studies have contested this conclusion by demonstrating appropriate rates of resolution when trephination of large hematomas was chosen over laceration repair. These authors also demonstrated increased rates of infection and resultant nail deformity in patients undergoing nail avulsion with laceration repair.¹⁰ Regardless, in instances where the hematoma spans greater than 50% of the nail plate, it is prudent to obtain an X-ray of the digit to rule out any concomitant phalangeal fracture. If phalangeal fracture is present, then exposure of the nail bed may be necessary to repair a laceration. Furthermore, in instances where the nail matrix is involved in a region of fracture, nail avulsion with repair of the laceration is indicated to prevent delay of fracture union or formation of an intraosseous inclusion cyst.¹¹

If the hematoma is less than 24 h old and comprises less than 25%–50% of the surface of the nail plate, then trephination with electrocautery or nail boring may be safely used. In resource-limited areas, a common approach has involved heating of a paper clip; however, as contemporary paper clips comprise aluminum alloys that may not reach a temperature adequate for penetrating the nail plate, this approach is advised against.

The clinician applies gentle pressure with the device of choice to the center of the hematoma, advancing until blood is liberated from the nail. Gentle pressure against the nail plate will then liberate the majority of the collected blood, resulting in near-immediate pain relief for the patient. If boring with a physical device is selected, use of an 18-gauge needle should produce a hole wide enough to prevent clotting over, which could result in reaccumulation of the blood. To prevent damage to the nail matrix, which could result in permanent nail splitting, trephination over the lunula is never indicated. Following the procedure, patients should be advised that oozing of blood from the trephination site is common for up to 24–48 h (Fig. 15.2).

Subungual haemorrhage | DermNet NZ

Author: Dr Mirain Phillips, Resident Medical Officer, Waikato Hospital, Hamilton, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof. Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. March 2020.

What is subungual haemorrhage?

Subungual haemorrhage is bleeding under a nail where blood is located between the nail matrix and nail plate. Subungual haemorrhage (escape of blood) is also called subungual haematoma (collection of blood).

Subungual haemorrhage

See more images of subungual haemorrhage.

What causes subungual haemorrhage?

Subungual haemorrhage is caused by an injury to the nail [1–3].

The types of precipitating injury may include:

A recalled painful event, most commonly involving a finger (eg, crush injury or blunt trauma) which may be associated with an underlying bone fracture.
A non-recalled repetitive micro-trauma, usually involving toes (eg, tight or ill-fitting shoes).

Rarely, subungual haemorrhage is associated with a malignant tumour of the nail unit, such as squamous cell carcinoma or melanoma [4].

What are the clinical features of subungual haemorrhage?

Subungual haemorrhage usually presents as a single discoloured or pigmented nail, which may be painless, tender, or painful.

The patient may remember an injury leading to intense pain due to the pressure from the pooling of blood in an enclosed space and damage to surrounding tissues. Reactive inflammatory changes, such as swelling and erythema, may be observed around the nail fold shortly after the injury.

Trauma may destroy or fracture the nail plate, resulting in the nail being opaque and yellowish due to detachment from the nail bed (onycholysis). The hyponychium (the skin under the free distal edge of the nail) may appear thickened due to blood between the nail plate and the nail bed.

Subungual haemorrhage may appear reddish, purple, brown, black, or a combination of these colours. The variation in colour is related to the duration and stage of healing [2].

A clear proximal margin in the nail plate appears within a few weeks due to normal nail growth after the injury and the discoloured nail plate grows outwards.

Subungual haemorrhage

How is subungual haemorrhage diagnosed?

Subungual haemorrhage is a clinical diagnosis supported by dermoscopy.

The dermoscopic features of subungual haemorrhage can include [2–4]:

Homogeneous or variable colours (reddish, purple, brown, or black)
Peripheral globular structures (also called clods) and streaks
Roundish shape with peripheral fading
Periungual haemorrhage
Linear white marks on the nail plate due to loss of transparency
Distal yellowing of the nail plate
Lack of malignant features.

The assessment of a pigmented nail should always evaluate the features that might be suggestive of subungual melanoma [4].

A plain X-ray should be considered for an acute injury to assess for an underlying fracture.

Subungual haemorrhage dermoscopy

What is the differential diagnosis for subungual haemorrhage?

The differential diagnoses to consider for nail pigmentation include:

Nail unit melanoma originating from the proximal nail matrix
Benign melanonychia due to a melanocytic naevus or lentigo in the proximal nail matrix
Nail fold infection (pseudomonas, dermatophyte, yeast, or mould)
Drug-induced nail diseases (these usually affect multiple nails)
Exogenous pigment (eg, henna, potassium permanganate, ink, or dye)
Inflammatory skin disease (eg, psoriasis, eczema, lichen planus).

Nail unit melanoma appears as a pigmented linear or triangular band along the entire length of the nail plate. It develops the following features over time:

Irregularity in pigmentation (light brown, dark brown, grey, or black)
Irregularity in the width and spacing of the pigmented bands
Ulceration or bleeding
Hutchinson sign (pigmentation in the skin proximal to the nail plate) and micro-Hutchinson sign (skin pigmentation visible on dermoscopy but not on clinical examination)
Nail dystrophy (cracking or deformity of the nail)
Subungual haemorrhage.

A normal-appearing proximal nail excludes a melanocytic lesion [5].

What is the treatment for subungual haemorrhage?

No treatment is required for subungual haemorrhage in the majority of cases. In the case of repetitive subungual haemorrhage, precipitating factors should be avoided, such as tight or ill-fitting shoes.

In the case of diagnostic uncertainty, the nail should be monitored using photography.

If subungual haemorrhage is acutely painful (< 48 hours after the injury), trephination can be considered [6,7]. Small holes are made in the nail plate to decompress and drain the haematoma. This can be done simply with a hot pointed metal implement [6].

Occasionally the nail plate is best removed, and the nailbed surgically repaired. A surgical opinion should be sought if there is an underlying fracture [7] or for biopsy if melanoma cannot be excluded.

Subungual haemorrhage surgery

What is the outcome for subungual haemorrhage?

Subungual haemorrhage resolves slowly over months to years, with toenails taking longer than fingernails to recover.

Progression of subungual haemorrhage

Selecting a treatment option in subungual haematoma management

VOL: 100, ISSUE: 46, PAGE NO: 59

Marion Richardson, BD, CertEd, RGN, RNT, DipN, is senior lecturer and programme leader, emergency nursing, University of Hertfordshire

A subungual haematoma is a collection of blood beneath a finger or toe nail.

It is often caused by a crush injury (Purcell, 2003) such as shutting a finger in a door or other types of trauma. Heim et al (2000) note that these haematomas can also be caused by repetitive trauma in athletes such as runners and dancers.

Systemic pathologies and medications may also cause subungual haematoma. Goodman et al (2002) cite melanoma, pemphigus vulgaris (autoimmune disease of the skin), blood dyscrasias and anticoagulant therapy as possible causes. Ghetti et al (2003) describe haematomas occurring under several nails resulting from chemotherapy. Buttaravoli and Stair (2004) mention melanoma, Kaposi’s sarcoma, and other tumours as possible causes. They note that if these are the causes, the history of the haematoma will not be consistent with a simple subungual haematoma.

Whatever the cause, subungual haematoma can be extremely painful (Heim et al, 2000) and a brief look at the anatomy of the nail will explain why.

Why is a subungual haematoma so painful?

The nail is a modification of the epidermis (the outer layer of the skin). It provides a protective covering and is very useful as a simple tool, for example when picking up small objects (Marieb, 2003). It contains keratin, which gives it its strength.

Each nail is attached to the surrounding skin by the cuticle or eponychium (Lumley, 2002), and is partly covered on three sides by nail folds (Fig 1).

Nails grow from a nail root situated proximal to the cuticle just below the skin on the dorsum of the finger or toe (Fig 1). The nail extends towards the tip of the digit over the nail bed or nail matrix (Marieb, 2003).

The nail bed has a very good arterial blood supply, which gives the nail its pinkish colour (Heim et al, 2000). There is also a very good nerve supply to the area, which allows us to feel all sorts of sensations, especially in our fingertips.

Trauma to the nail damages the tiny blood vessels and the resultant bleeding that can occur under the fingernail puts pressure on the many nerve endings in the nail bed, causing considerable local pain.

The nail is firmly attached to the nail bed and the two apposing surfaces are ridged to strengthen this bond (Goodman et al, 2002). There is no subcutaneous fat in the nail bed to cushion any trauma and because it is so close to the underlying distal phalanx (the bones of the fingers and toes), concurrent trauma to the bone is not uncommon.

Presenting symptoms

A subungual haematoma causes marked tenderness as blood accumulates under tension in the nail bed (Goodman et al, 2002). Patients often present in acute care settings with pain caused by these injuries.

Views differ as to how these haematomas should be treated. The most common treatment is to trephine, or make a hole, in the nail to release the blood, reduce the pressure, and thus relieve the pain (Fig 2).

Treatment options

Kukula and Fell (2003) suggest that haematomas only need to be drained if they cover 25 per cent or more of the nail. They suggest leaving them to resolve spontaneously if they are smaller than this.

A number of authors, including Wang and Johnson (2001), recommend that when the haematoma covers 50 per cent of the nail or more, the nail should be removed and the nail bed repaired.

Batrick et al (2003) reviewed 312 papers to see whether research demonstrated that this additional intervention improved cosmetic and functional results. They conclude that there are insufficient studies to support nail removal and nail-bed repair, and that treatment by trephining gives a good cosmetic and functional result in adults and children who have a subungual haematoma but no other significant fingertip injury.

Buttaravoli and Stair (2004) suggest that splinting a lacerated nail bed by its own nail may be superior to suturing. They recommend that if there are obvious lacerations with open haemorrhage or broken nails, a digital block should be performed and the nail should be lifted for inspection of the nail bed and repair of any lacerations. Nails that have become loose at a nail fold, whether at the sides or the root, should be resited (Purcell, 2003).

Meek and White (1998) found that only two per cent of patients treated with simple trephining had a ‘poor’ outcome with nail splitting, and that the occurrence of these poor outcomes could not be predicted. These authors suggest that treatment with simple trephining is effective even if the haematoma is large.

Management when the terminal phalanx is fractured

There is a debate as to whether trephining should be used when the underlying terminal phalanx is fractured. Purcell (2003) reminds us that fracture should be excluded, as trephining a nail over such an injury will technically turn the fracture from a closed to an open one. This increases the risk of infection tracking down to the bone and causing osteomyelitis.

There are a number of treatment options but perhaps the best advice is that given by Buttaravoli and Stair (2004). They suggest that trephining a nail with an underlying fracture should only be carried out when there is sufficient pain to justify it.

If trephining is used, the patient should understand the potential risk of developing osteomyelitis, as well as the need to keep the finger clean and dry.

Some authors recommend the use of prophylactic antibiotics, but there is little empirical evidence to support their use.

Avulsion (tearing) of the extensor tendon from the distal phalanx of the digit is another possible complication that must not be overlooked (Buttaravoli and Stair, 2004).

Time lapse from injury

Buttaravoli and Stair (2004) suggest that 24 hours after the injury the pain will have subsided anyway so trephining may not significantly improve discomfort, but will expose the patient to the risk of infection.

Purcell (2003) says there is no benefit in trephining once the blood has congealed, but that this can take up to a week and helpful results may be achieved during that time.

Consensus on treatment

The consensus of opinion would seem to be that as long as the nail and nail margins are intact and there is no other underlying trauma, simple trephining is the preferred method of relieving pain in a traumatic subungual haematoma where the patient is experiencing pain at rest.

Practitioners should only carry out treatments for subungual haematoma following local policies and guidelines.

Methods for trephining

The haematoma should be drained under aseptic conditions. It is important to ensure that universal precautions for blood and body fluid are adhered to, as the blood is under pressure and may spurt out (Buttaravoli and Stair, 2004). Anaesthesia of the digit should not be necessary.

A number of different methods can be used to make a hole in the nail. These include:

– Hot cautery;

– A fine-point scalpel blade;

– Electrocautery;

– Surgical drill;

– Laser.

Whatever method is used, it is essential to ensure that the hole is large enough to allow free drainage of the haematoma; it may be necessary to move the trephining instrument from side to side. Failure to do this may mean that the haematoma clots and reseals.

Hot cautery

A very simple method involves the use of a paper clip with its tip heated in a spirit-flame lamp until it is red hot. It is extremely effective when carried out by a skilled practitioner. The procedure can be carried out quickly except when the nail is very thick (Purcell, 2003).

Bache et al (1998) describe the method in detail, noting that the hot tip of the paper clip should be applied to the central point of the haematoma.

A specially designed electronically heated cautery tip can also be used.

Buttaravoli and Stair (2004) recommend that sufficient pressure needs to be applied to melt through the nail. Simply holding the instrument in place can heat up the nail and increase the pain without making a hole in it. Pressure should be maintained until the operator feels a ‘give’ as the instrument passes through the nail. Patients may find the smell of burning nail unpleasant.

Caution should be exercised when using hot cautery trephination on a patient wearing artificial acrylic nails as these are flammable (Buttaravoli and Stair, 2004).

Drilling

A special battery-powered drill can be used to make a hole in the nail. Alternatively, a large-gauge (white) hypodermic needle can be twisted back and forth between the operator’s fingers. Pressure needs to be maintained until the nail ‘gives’.

Fine-point scalpel blade

A number 11 scalpel blade can be used to cut a hole in the nail. The scalpel makes a bigger hole and this probably improves drainage, but the procedure is slower and more painful (Purcell, 2003).

Laser treatment

Laser treatment is not commonly used to trephine nails. This method should only be performed by practitioners skilled in using laser equipment.

Insulin needle

An article by Kaya et al (2003) describes a technique for evacuating the haematoma using a very fine 29-gauge insulin needle inserted very close to the nail plate. This method was found to be fast and simple and patients tolerated it. It is recommended for small haematomas of the second, third, and fourth toenails where trephining is more difficult. Further research is needed to confirm how useful this technique is.

Aftercare and patient advice

Once the nail has been trephined, the area should be gently squeezed to express the blood (Bache et al, 1998). A pressure dressing will continue to squeeze out the haematoma and help resite the nail on the nail bed (Goodman et al, 2002). The dressing is usually left in place for about two days.

Patients should be advised to keep the area clean and dry in order to minimise the risk of infection of the nail bed. This is particularly important if the decision has been made to trephine a nail with an underlying distal phalanx fracture.

The haematoma will usually grow out with the nail, but nail deformity and permanent abnormalities can occur (Kukula et al, 2003) and patients should be warned of this. Normally, preserving the intact nail root and nail bed will ensure growth of a normal nail, but if the bed is damaged and scarred all future nails will be deformed (Heim at al, 2000).

Conclusion

Subungual haematoma, an apparently minor injury, can be extremely painful. Trephining is an effective method of releasing trapped blood and relieving pain, but nurses should know the treatment options and possible pitfalls to provide optimum care for patients.

Subungual Hematomas and Trephination – CanadiEM

Case Presentation

You are a clinical clerk on your rural family medicine rotation working in the local emergency department. Your preceptor asks you to see a 25-year-old male who presents shortly after having hit his left index finger with a hammer while building a new deck this afternoon. He is otherwise healthy, he is not taking any medications, and he has no known drug allergies. He is right-handed and works as an electrician. He appears well, his vital signs are within normal limits, and he denies any other injuries besides his left index finger. The involved fingernail is intact, but there is an area of dark blue-black discolouration starting at the proximal nail fold and involving more than 50% of the nail. The remainder of the left second finger and hand appear normal. There is no obvious bleeding or deformity. The involved finger has normal neurovascular status and normal extension at the distal interphalangeal (DIP) joint.

Management Plan

As you review a management plan with your preceptor, she asks you a few questions

1. What is the medical name for this injury?

A subungual hematoma refers to the collection of blood under a fingernail or toenail following a traumatic injury to the distal phalanx. Patient’s often present with blue-black discoloration under the nail and describe the pain as throbbing

2. What are the clinically relevant features of nail anatomy?

Nail Folds: the nail is surrounded on three sides by the lateral and proximal nail folds.
Lunula: the white crescent-shaped area of the nail along the proximal nail edge. This corresponds to the distal portion of the nail matrix.
Nail Matrix: a collection of specialized epithelial cells that are responsible for nail growth. It begins 7-8 mm under the proximal fold and its distal end is the lunula. The matrix is anchored to the periosteum of the distal phalanx.
Nail bed: highly vascularized area of skin underneath the nail that is adherent to the nail.

Adapted from: Patel L. Management of simple nail bed lacerations and subungual hematomas in the emergency department. Ped Emerg Care 2014; 30:742. DOI: 10.1097/PEC.0000000000000241. Copyright © 2014 Lippincott Williams & Wilkins.

3. What other injuries are important to rule out that are commonly associated with this injury?

Distal phalanx fracture
Mallet finger – injury to the distal extensor tendon
Fingertip avulsion
Nail bed laceration

4. Does this patient need an X-ray of the affected digit?

Distal phalanx fractures are commonly associated with subungual hematomas, especially when the hematoma involves more than 50% of the nail bed. In one series of 47 patients with subungual hematoma, 32% had an associated distal phalangeal fracture.¹^{Given that the presence of a fracture of the distal phalanx would affect our management plan, it would be reasonable to obtain AP, lateral, and oblique views of his injured finger.}

5. Some subungual hematomas will require a procedure called nail trephination. What is nail trephination? Describe the indications, contraindications, potential complications, and procedure.

Nail Trephination

Nail trephination is the process of making a hole in a nail to drain a subungual hematoma. Nail trephination is most likely to be successful if performed within 48 hours of injury.

Indications³

Painful/symptomatic
- Large hematoma involving more than 50% of the nail

Contraindications (for electrocautery trephination)

Acrylic nails (flammable!)

Complications

Secondary infection of the nail bed and deeper structures
Pain caused by pressure against or contact with the nail bed during the procedure
Potential for clotting to plug the nail hole, leading to reaccumulation of blood

Procedure

The most common methods of trephination are with electrocautery or using a needle to bore through the nail.

Steps for electrocautery trephination:

Remember to wear eye protection, a procedure mask, and gloves, as sometimes the blood may spurt from the nail under high pressure.
In selected patients, perform a digital block or sedation. This step is often not required, as performing the nerve block is often more painful than the trephination itself.
Clean the nail with povidone iodine swabs using sterile technique. Isopropyl alcohol is highly flammable and should be avoided if electrocautery is used.
Puncture the nail with an electrocautery device. Press the device against the nail in the center of the hematoma while avoiding the lunula and its associated nail matrix. Avoid contact with nail bed. The hole should be large enough (3 to 4 mm) for continued drainage, which may occur for 24 to 36 hours after injury.

Steps for needle trephination:

Remember to wear eye protection, a procedure mask, and gloves, as sometimes the blood may spurt from the nail under high pressure.
In selected patients, perform a digital block or sedation. This step is often not required, as performing the nerve block is often more painful than the trephination itself.
Select a large gauge needle (e.g., 18 gauge) for trephination.
Use a twirling motion with gentle downwards pressure to create a hole in the nail until blood begins to drain. Again, be careful to avoid the lunula so as to not damage the underlying nail matrix. Usually one hole created with a larger gauge needle is sufficient, but multiple holes may be required if you choose to use a smaller gauge needle.

What about using a heated paper clip?

The classic technique of using a heated paper clip is probably best reserved for situations where there are no other alternatives available. Nowadays, most paper clips are made of metals like aluminum that are very difficult to heat sufficiently to melt through a nail.⁴ Furthermore, the rapid cooling of the paperclip means that excess pressure may need to be applied to melt the nail, causing excess pain for the patient and the potential for injury to the underlying nail bed due to sudden penetration of the nail with excess force.

6. Does the fingernail need to be removed to rule-out a nail bed laceration?

Nail removal was traditionally recommended for hematomas that involved more than 25 to 50 percent of the nail or if a fracture was found on radiographs, as these features were associated with nail bed lacerations longer than 2 to 3 mm. It was thought that these nail bed lacerations should be repaired to prevent long-term nail deformity.

However, more recent evidence supports the use of trephination in patients with intact nail folds even when large hematomas or non-displaced underlying fractures are present. Nail removal and laceration repair is not required for these patients with intact nail folds as it has not been shown to result in improved short- or long-term outcomes such as reduced rates of infection or nail deformity.^5,6

That being said, nail removal should be performed when a nail laceration threatens the preservation of the nail or digit. For example, patients with nail fold injuries, broken nails, or clear fingertip or toe avulsion injuries should have the nail removed to facilitate proper repair of the underlying nail bed.

7. If the patient has an associated distal phalanx fracture, what is the management?

Even though a subungual hematoma with an underlying fracture can technically be considered an open fracture, patients with intact nail folds do not routinely require prophylactic antibiotics after trephination.⁶

Nondisplaced distal phalanx fractures should be splinted with the DIP joint in extension for three to four weeks.

Consultation with a hand surgeon should be considered for patients with displaced or intraarticular distal phalanx fractures.

8. What would your discharge instructions be?

The digit should be kept clean and dry to lower the risk of bacterial infection. Patients should return to care if there is reaccumulation of the hematoma with pain or if any signs of infection develop (e.g., warmth, redness, or fever).

Case Conclusion:

After a detailed discussion with your preceptor, you apply what you have learned to John’s case. He has an acute, painful, non-draining subungual hematoma with intact nail folds, making him a good candidate for trephination. Given the size of his hematoma (involving >50% of the nail), you appropriately obtain radiographs of the affected finger, which do reveal a non-displaced extraarticular fracture of the distal phalanx of the left second finger. After obtaining informed consent, you use an electrocautery to trephinate his nail, being careful to avoid the lunula, which results in drainage of the trapped blood. You then provide John with a splint to keep his finger in extension for 3 to 4 weeks to allow his fracture to heal. You encourage him to keep his finger dry and clean over the next couple of days and to return to care if he is at all concerned about reaccumulation of blood or infection. He thanks you for your care and states that his pain is already greatly improved.

This post was edited by Daniel Ting and copyedited by @jamievanderende.

1.
Simon RR, Wolgin M. Subungual hematoma: Association with occult laceration requiring repair. The American Journal of Emergency Medicine. Published online July 1987:302-304. doi:10.1016/0735-6757(87)90356-1
3.
Mailot T, Lyn E. Fingertip Injuries. In: Rosens Emergency Medicine. Saunders; 2014:561-562.
4.
Antevy P, Saladino R. Management of finger injuries. In: Textbook of Pediatric Emergency Procedures . 2nd ed. Lippincott Williams & Wilkins ; 2008:929.
5.
Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. The Journal of Hand Surgery. Published online November 1999:1166-1170. doi:10.1053/jhsu.1999.1166
6.
Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: A prospective study. The American Journal of Emergency Medicine. Published online May 1991:209-210. doi:10.1016/0735-6757(91)90077-w

Reviewing with Staff

Fabulous summary of subungual hematomas. This is a very common and particularly painful condition. Nail plate trephination is so fast and satisfying to provide instant pain relief without analgesia.

Please do not forget to have a very low threshold to x-ray. I have had 2 recent distal phalanx open fractures fully hidden underneath the subungual hematomas. These were more involved and can require nail plate removal, extensive washout, nailbed laceration repair, antibiotics, and plastics consults for hand clinic follow-up. In 2020 in Calgary, I\’ve had plastics surgeons expect open washout and repair prior to hand clinic follow-up. Local practice may vary.

Stephane Kallos

Stephane Kallos is a proud father of 3 and enjoys a very broad scope of practice in Family Medicine and beyond. He works in Calgary at the Sunridge Family Medicine Teaching Clinic as a Preceptor / Competency Coach in Family Medicine. He gets his exposure to acute care in Airdrie\’s 24-hour Urgent Care Center and provides overnight coverage at the Peter Lougheed Center as an Intensive Care outreach physicians. He is a Medical Informatics Lead for Connect Care and the co-chair of the Primary Care are council. No conflicts of interest

(Visited 2,478 times, 9 visits today)

Levi is a proud husband and father currently completing his Family Medicine residency in Calgary. He is interested in medical education, PoCUS, and Emergency Medicine in general. He has no conflicts of interest.

Subungual hematoma & subungual hematoma treatment or nail trephination

Subungual hematoma or bleeding under a nail plate, is a purple mark under the nail due to bleeding or bruising. Subungual hematoma results in painful or unnoticed purplish-black discoloration. The discoloration may persist for months as the nail carries the blood with it as it grows out.

Subungual hematoma is usually caused by a traumatic injury as in hitting your thumb with a hammer or stubbing a toe. Subungual hematoma can also occur from wearing tight-fitting shoes which trap blood in the toes leading to an increased pressure within the blood vessels of the toes. In either case, the injury leads to the breakage of small blood vessels underneath the nail which leak blood into a potential space below the nail that causes discoloration of the nail and intense pressure.

Initially the injury may only hurt. The nail may feel sore or tender to the touch. As the blood pools under the nail the pressure from the blood can cause severe pain. The pressure caused by blood underneath the nail may result in the affected nail lifting off the finger or toe. The color under the nail will change over time initially red to purple and later to dark brown and black as the blood clots. The pain usually resolves days after the injury and the nail looks worse than it feels.

There are a few reasons to seek medical attention: if bleeding does not stop, if the pain becomes too intense, or if there is significant injury to the base of the nail. Depending on the manner of injury, issues to be aware of would be; a deep cut or laceration to the skin of the finger or toe underneath the nail that may require stitches as well as taking an x-ray to determine if the bone of the finger or toe involved is broken. If necessary the pressure caused by the hematoma can be resolved by a medical professional using a technique called trephination. This is done by using a sharp instrument to pierce the nail and drain the blood which relieves the pain. Drainage or removing the nail is discouraged from being attempted by the public because this could lead to further complications of infection, additional trauma, slowing of the healing process, or leaving the finger or toe vulnerable.

Over the course of several months a new nail replaces the damaged, discolored nail. There usually is no need for further treatment or follow up.

When to see your doctor

See your doctor if:

Redness, pain, or swelling increases
Pus (yellow or white fluid) drains from the wound
You have a fever
You have bleeding that does not stop

Subungual hematoma treatment

Usually the treatment is minimal and consists of rest, ice, elevation, and compression of the finger or toe. Over the counter pain medication can be given if needed. Elevation and the use of ice help to reduce the swelling and further pain. Placing ice directly on the affected nail could cause further injury, so wrapping ice in a cloth towel and applying it to the affected area works best. Compression can further reduce the bleeding underneath the nail.

What you can do for subungual hematoma:

Apply ice for 20 minutes every 2 hours on the first day, then 3 to 4 times a day after that.
To reduce the throbbing, keep your hand or foot above the level of your heart.
Take prescription pain relievers as directed. Or you can use ibuprofen or naproxen to reduce pain and swelling. Acetaminophen helps with pain, but not swelling. You can buy these pain medicines without a prescription.
- NOTE: Talk with your doctor before using these medicines if you have heart disease, high blood pressure, kidney disease, or have had stomach ulcers or internal bleeding in the past. DO NOT take more than the amount recommended on the bottle or by your doctor.

Regardless of treatment the hematoma will eventually be resorbed by the body and a new nail will grow out. On average the nail takes 6 to 9 months to grow completely out. Toenails take about 12 months to grow back. A complication to be aware of is damaging the cells that re-grows the nail (the nail matrix). If the nail matrix is damaged the nail will grow incorrectly or may not re-grow a nail. The new nail will probably have grooves or ridges and be somewhat misshapen. This may be permanent.

For more serious nail injuries, you should go to an urgent care center or the emergency room. They will stop the bleeding and clean the wound. Usually, the nail and finger or toe will be numbed with medicine before it is treated.

For a larger bruise, your doctor will create a small hole in the nail.
This will allow fluid to drain out and relieve the pressure and pain.
If the bone is broken or the bruise is very large, the nail may need to be removed and the nail bed repaired.

If you broke a bone in your finger or toe along with the nail injury, it will take about 4 weeks to heal.

Draining subungual hematoma

Small or painless hematomas and hematomas that are already draining need not be trephined. Hematomas confined to the lunula should not be trephined. If you suspect underlying nail-bed injury or fracture of the phalanx, trephining should not be attempted.

Draining is indicated to relieve pain caused by subungual hematomas when the nail edges are unaffected. The decision to perform this procedure is based on the degree of pain, rather than the size of the hematoma. The video reviews the technique and equipment required.

Choose a sterile, disposable, 23-gauge double-bevel 1-inch needle. Note that when choosing the needle, there is a trade-off between bore size and bevel length. Hold the needle between the thumb and third finger and steady the needle on top of the hub with your index finger. Place the needle over the nail and the hematoma, choosing a position by comparing the landmarks with the corresponding contralateral fingernail so as to avoid the lunula. With the thumb and third finger, rotate the needle back and forth. The double bevel acts as a drill, slowly penetrating the nail. No pressure needs to be applied to the needle by the index finger. Just as the needle penetrates the nail, a small bead of blood will appear in the drilled hole, telling the doctor to slow down and complete the last of the drilling maneuver with extra care to avoid the underlying nail bed.

Subungal Hematoma

Kids love to explore their environment, but sometimes that environment (and their lack of agility and sluggish reflexes) leads to injuries. Fortunately, often these injuries are minor. Unfortunately, those minor injuries can lead to major headaches for you in your ED. One great example of that is the possible nail bed injury. Is that simple subungal hematoma really simple, or does it warrant a big procedures?

Hand injuries are commonly seen in children. [Shah, 2012]
- In the US, from 1990-2009, ~16.4 MILLION kids were treated in EDs for hand injuries!
- That is equivalent to 2,243 children per day!
Fingertip and nail bed injuries are some of the more common hand injuries in kids. [Gellman, 2009; Doraiswamy, 1999]
The middle finger is most commonly injured finger (sometimes it isn’t beneficial to be longer).

Fingertip injuries can be associated with nail bed injuries (in 15-24% of cases).
A nail bed injury that is not managed correctly can lead to chronic deformity of the nail bed, nail plate, and finger tip. [Patel, 2014; Fairborn, 2012].
This can also affect the finger’s function.
Significant nail bed injuries can present in subtle ways initially (i.e., subungal hematoma).

It is important to evaluate the nail bed for possible injury and repair them as needed.
- Obviously, if there is a laceration through the nail plate involving the nail bed, the nail plate needs to be removed and necessary repairs made, but…
A “significant” subungal hematoma may indicate nail bed injury also.
- >50% of the nail surface
- >25% with an associated fracture.
This would equate to needing to remove the nail plate in the setting of significant subungal hematoma.
Certainly, EM physicians can manage these potential issues and have similar outcomes to other specialists, so there is no need to delay treatment by making consultant phone calls. [Al-Qadhu, 2011]

Removing the nail plate is not easy in adults, and can be very challenging in children.
- Tiny digits with delicate structures are more challenging to manipulate.
- The procedure may also require sedation.
Removing the nail plate may harm the nail bed even more.
- Again, dedicated structures don’t react well to giant instruments.
Removing the nail plate leads to greater monetary expenses! [Roser, 1999]

Based on current literature (as noted by Patel, 2014), in the setting of a Subungal Hematoma, the nail plate DOES NOT need to be removed if:
- If the nail plate is intact and at least partially adherent to the nail bed,
- AND
- If there is a fracture, it is not significantly displaced.
Nail trephination has been shown to produce similar cosmetic and functional outcomes with no increased complications regardless of size of the subungal hematoma. [Roser, 1999; Meek, 1998; Seaberg, 1991]

Stated another way, an uncomplicated subungal hematoma can be treated with simple trephination.

Electrocautery device or red-hot paperclip can be used to create hole(s) in the nail plate to decompress the subungal hematoma.
The procedure is rapid and the heat of the electrocautery/paperclip is dissipated by the hematoma so it does not damage the underlying nail bed. [Patel, 2014]
A sterile needle can also “drill” through the nail plate, but care needs to be taken to not damage the underlying nail bed.

Fairbairn N1. No such thing as “just” a nail bed injury. Pediatr Emerg Care. 2012 Apr;28(4):363-5. PMID: 22472652. [PubMed] [Read by QxMD]

Nail bed injuries are the commonest pediatric hand injuries presenting to the emergency department. If managed correctly, the patient recovers quickly and complications are rare. However, failure to appreciate the complex anatomy of the perionychium and the importance of exploration, washout, and repair can result in devastating complications. These injuries are often underestimated and, consequently, delegated to the most junior and inexperience […]

Roser SE1, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 1999 Nov;24(6):1166-70. PMID: 10584937. [PubMed] [Read by QxMD]

Fifty-three fingers in 52 children were divided into 2 groups, operative and nonoperative, after fingernail crush injury. Criteria for inclusion into the study were an intact nail and nail margin with subungual hematoma and no previous nail abnormality. The length of the follow-up period averaged longer than 2 years for each group. Twenty-six fingers in 26 children were treated by nail removal, exploration, and repair of nail bed lacerations (ope […]

Seaberg DC1, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991 May;9(3):209-10. PMID: 2018587. [PubMed] [Read by QxMD]

Subungual hematoma is a commonly encountered problem in the emergency department. We designed a prospective, observational study to determine if treatment of simple subungual hematomas (SUH) by nail trephination alone is without cosmetic or infectious complications. Over a 2-year study period, 48 patients met inclusion criteria. Radiographs of all digits were taken to detect distal phalangeal fracture and SUH size was measured. Nail trephination […]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

Articles: 549

90,000 Subungual hematoma – causes, symptoms, diagnosis and treatment

Subungual hematoma is a consequence of mechanical trauma to the nail phalanx of the upper or lower extremity, in which hemorrhage occurs in the soft tissues of the nail bed. The damage is characterized by pain of varying degrees of intensity, a local increase in temperature, edema, the appearance of red, and then bluish and black staining of the nail plate. Diagnosis is based on history and clinical presentation.In most cases, no treatment is required. Detachment of the nail plate, laceration of soft tissues is an indication for surgical treatment of the damaged area, suturing and dressing.

General information

Synonymous names are used to denote pathology: bruise under the nail, “blue nail”. Throughout life, each person suffers such bodily harm, sometimes more than once. More often, injuries are recorded in males of working age.The peak of injuries occurs during the warm season and the vacation period, when most are engaged in construction and repairs, work on personal plots, and actively resting in nature. The overwhelming majority of cases of subungual hemorrhage remain outside the field of vision of doctors, since patients often consider the damage to be insignificant and simply ignore it.

Subungual hematoma

Causes

In the development of subungual hematomas, physical impact and a number of predisposing factors play a role.Thus, the risk of bleeding in response to minor trauma increases in patients taking anticoagulants. Patients with diabetes mellitus and other diseases in which polyneuropathy develops, tactile and pain sensitivity are impaired late, notice damage. The main reasons for the appearance of subungual hematomas are:

Sharp directional impact. A contusion of the terminal phalanx, depending on the strength of the impact, can lead to damage to the vessels of the skin, crushing of tissues, the appearance of a laceration, and bone fracture.Each of these injuries is characterized by an accumulation of blood under the nail. Therefore, any injury requires medical attention.
Prolonged mechanical stress. Wearing shoes of the wrong size and fullness leads to injury to the nail plates and the skin beneath them. In fact, a callus develops, which fills with serous fluid or blood. In this case, the nail plate may peel off completely or partially.

Pathogenesis

The development of a subungual hematoma is based on a violation of the integrity of the vessels. The spilled blood soaks the tissues, including the nail plate. If the blood volume is insignificant, the structure of the soft tissues is preserved. If the volume and rate of bleeding are significant, then under the pressure of the blood, soft tissues exfoliate with the formation of a cavity. A hematoma that has formed under the skin at the hole or in the area of the nail bed, as the nail grows, moves in the distal direction.Blood pressure in the area of the hematoma irritates the nerve endings, which provokes pain. A sharp increase in hematoma volume leads to the formation of a subungual space or a breakthrough of blood near the nail folds.

The blood soaked in soft tissues is gradually absorbed. The staining of the nail plate is irreversible. Over time, the blood clot loses moisture, becomes first dark blue, then blackens. In both cases, a spot is formed, which moves to the free edge of the nail plate.

Classification

Often the terms “hematoma” and “bruising” are used interchangeably, but this is not entirely true. The differences between these two conditions relate to the mechanisms of injury, the clinical picture of the disease, the duration of forced temporary disability due to limb injury, and medical approaches to treatment.

Subungual bruise. It develops as a result of the impregnation of the skin and subcutaneous tissue with blood from damaged vessels.As a rule, it is formed with an insignificant effect and is characterized by unexpressed symptoms. The patient’s condition is quickly normalized, the functioning of the limb is restored.
Subungual hematoma. Differs from bruising by dissection of tissues with the formation of a cavity filled with blood. Hemorrhagic impregnation also takes place, however, the volume of blood poured out is much larger than with bruising, which increases the likelihood of nail detachment and the development of other complications.

Symptoms of the subungual hematoma

The characteristic signs of hemorrhage in the subungual region that developed after trauma are local hyperemia, fever, edema, pulsating or bursting pain. The peak of the local temperature rise occurs 2-3 hours after the injury. On the 2-3rd day, the pain subsides, the swelling begins to subside.

Immediately after injury, the nail acquires a deep red or cherry-purple color. On the second or third day, the affected area turns blue, after another week or two it acquires an intense black color.The blood-soaked portion of the nail is gradually moved towards the nail edge and cut off. Thus, the black spot can persist for 2-3 months.

In cases where the cause of injury is the wearing of uncomfortable shoes, there may be slight soreness or discomfort. But more often, a change in the color of the nail plate becomes an accidental find during the implementation of foot care. Simultaneously with the color change, exfoliated fragments of the plate, calluses on the skin of the fingers in the area of the nail ridges are often revealed.

Complications

Damage to the skin and base of the nail leads to its deformation. The severity and duration of the deformation is determined by whether the growth zone was affected. Normally, the deformed areas are cut off with scissors during the manicure. Trauma to the base of the nail plate leads to persistent deformity that does not disappear over time. The appearance of a crack or chipped nail as a result of mechanical action creates conditions for the penetration of infection and the development of purulent inflammation of damaged tissues.Microorganisms multiply especially actively in the hematoma cavity. Insufficient care of the bruised phalanx can cause the development of felon.

Diagnostics

In appearance, subungual hematomas have similar features to onychopathies in psoriasis, melanoma. The degree of damage to the finger on impact is not always obvious. In this regard, it is better to consult a surgeon, even if the injury seems frivolous. Comprehensive examination of a patient with phalanx injury includes:

General examination .A hematoma is indicated by the presence of a previous mechanical effect, an acute course with a rapid increase in symptoms. Palpation of the damaged area is painful. Drainage, which can be performed directly during the outpatient appointment, has a quick effect.
X-ray examination . An X-ray of a finger is performed to detect a violation of the integrity of the bones and joints of the limb. According to the X-ray data, it is possible to judge the presence of a fracture, but it is impossible to draw unambiguous conclusions about the degree of damage to soft tissues (skin, tendons, muscles), the volume of the hematoma.

Treatment of subungual hematoma

Medical tactics are determined by the severity of the injury. Indications for seeking medical help are intense, unbearable pain in the area of the injured phalanx and the size of the hematoma over ¼ of the nail area. The scope of medical care is determined by the surgeon on the basis of examination and X-ray data:

First aid. Proper care of the damaged phalanx allows you to quickly relieve pain, stop or slow down bleeding, and prevent detachment of the nail plate.Immediately after the injury, you must immerse your finger in a container of cold water for 15-20 minutes. Then, if there is an open wound, treat the damaged area with an antiseptic solution and apply a bandage.
Drainage of hematoma. The nail plate over the hematoma is punctured with a needle or burned out with a thermocoupler. The outflow of blood through a small hole leads to a decrease in pressure on the tissues, a decrease in the intensity of pain. A drained subungual hematoma dissolves faster, which is important for patients who need not have cosmetic defects on their hands.
Removal of the nail plate. The nail plate is removed partially or completely when it is detached from the nail bed. Attempts to save the nail can lead to unfavorable consequences: detached fragments disrupt the normal functioning of the finger, and can cause additional injury in case of accidental separation.
Surgical debridement. Crushing injury of tissues, laceration, bone fracture require PST, which includes removal of non-viable fragments, suturing, drainage.The purpose of medical manipulations is to create optimal conditions for healing, prevention of dysfunction of the foot or hand, and purulent-septic complications.
Whitening of damaged nail. The blood-soaked nail plate grows back within a few months. To eliminate a cosmetic defect in one procedure, the injection subungual injection of special bleaches allows. In this case, the black spot is completely discolored. Topically applied whitening drugs do not give a noticeable effect.

Forecast and prevention

In the overwhelming majority of cases, the subungual hematoma goes away on its own without treatment. Within a month or two, only a cosmetic defect in the form of a dark spot on the nail reminds of the injury. As a preventive measure, it is recommended to observe safety precautions and accuracy when performing work, closing doors, moving goods. Properly selected sports and casual shoes allow you to maintain the health of your feet. To protect the fingers, it is recommended to use special work gloves and various devices that reduce the likelihood of damage to the upper limbs (grips, clamps, manipulators).

90,000 Subungual hematoma – causes, symptoms, diagnosis and treatment

Subungual hematoma is a consequence of mechanical trauma to the nail phalanx of the upper or lower extremity, in which hemorrhage occurs in the soft tissues of the nail bed. The damage is characterized by pain of varying degrees of intensity, a local increase in temperature, edema, the appearance of red, and then bluish and black staining of the nail plate.Diagnosis is based on history and clinical presentation. In most cases, no treatment is required. Detachment of the nail plate, laceration of soft tissues is an indication for surgical treatment of the damaged area, suturing and dressing.

General information

Synonymous names are used to denote pathology: bruise under the nail, “blue nail”. Throughout life, each person suffers such bodily harm, sometimes more than once.More often, injuries are recorded in males of working age. The peak of injuries occurs during the warm season and the vacation period, when most are engaged in construction and repairs, work on personal plots, and actively resting in nature. The overwhelming majority of cases of subungual hemorrhage remain outside the field of vision of doctors, since patients often consider the damage to be insignificant and simply ignore it.

Subungual hematoma

Causes

Sharp directional impact. A contusion of the terminal phalanx, depending on the strength of the impact, can lead to damage to the vessels of the skin, crushing of tissues, the appearance of a laceration, and bone fracture.Each of these injuries is characterized by an accumulation of blood under the nail. Therefore, any injury requires medical attention.
Prolonged mechanical stress. Wearing shoes of the wrong size and fullness leads to injury to the nail plates and the skin beneath them. In fact, a callus develops, which fills with serous fluid or blood. In this case, the nail plate may peel off completely or partially.

Pathogenesis

Classification

Subungual bruise. It develops as a result of the impregnation of the skin and subcutaneous tissue with blood from damaged vessels.As a rule, it is formed with an insignificant effect and is characterized by unexpressed symptoms. The patient’s condition is quickly normalized, the functioning of the limb is restored.
Subungual hematoma. Differs from bruising by dissection of tissues with the formation of a cavity filled with blood. Hemorrhagic impregnation also takes place, however, the volume of blood poured out is much larger than with bruising, which increases the likelihood of nail detachment and the development of other complications.

Symptoms of the subungual hematoma

Complications

Diagnostics

General examination .A hematoma is indicated by the presence of a previous mechanical effect, an acute course with a rapid increase in symptoms. Palpation of the damaged area is painful. Drainage, which can be performed directly during the outpatient appointment, has a quick effect.
X-ray examination . An X-ray of a finger is performed to detect a violation of the integrity of the bones and joints of the limb. According to the X-ray data, it is possible to judge the presence of a fracture, but it is impossible to draw unambiguous conclusions about the degree of damage to soft tissues (skin, tendons, muscles), the volume of the hematoma.

Treatment of subungual hematoma

First aid. Proper care of the damaged phalanx allows you to quickly relieve pain, stop or slow down bleeding, and prevent detachment of the nail plate.Immediately after the injury, you must immerse your finger in a container of cold water for 15-20 minutes. Then, if there is an open wound, treat the damaged area with an antiseptic solution and apply a bandage.
Drainage of hematoma. The nail plate over the hematoma is punctured with a needle or burned out with a thermocoupler. The outflow of blood through a small hole leads to a decrease in pressure on the tissues, a decrease in the intensity of pain. A drained subungual hematoma dissolves faster, which is important for patients who need not have cosmetic defects on their hands.
Removal of the nail plate. The nail plate is removed partially or completely when it is detached from the nail bed. Attempts to save the nail can lead to unfavorable consequences: detached fragments disrupt the normal functioning of the finger, and can cause additional injury in case of accidental separation.
Surgical debridement. Crushing injury of tissues, laceration, bone fracture require PST, which includes removal of non-viable fragments, suturing, drainage.The purpose of medical manipulations is to create optimal conditions for healing, prevention of dysfunction of the foot or hand, and purulent-septic complications.
Whitening of damaged nail. The blood-soaked nail plate grows back within a few months. To eliminate a cosmetic defect in one procedure, the injection subungual injection of special bleaches allows. In this case, the black spot is completely discolored. Topically applied whitening drugs do not give a noticeable effect.

Forecast and prevention

90,000 Subungual hematoma – causes, symptoms, diagnosis and treatment

Subungual hematoma is a consequence of mechanical trauma to the nail phalanx of the upper or lower extremity, in which hemorrhage occurs in the soft tissues of the nail bed. The damage is characterized by pain of varying degrees of intensity, a local increase in temperature, edema, the appearance of red, and then bluish and black staining of the nail plate.Diagnosis is based on history and clinical presentation. In most cases, no treatment is required. Detachment of the nail plate, laceration of soft tissues is an indication for surgical treatment of the damaged area, suturing and dressing.

General information

Synonymous names are used to denote pathology: bruise under the nail, “blue nail”. Throughout life, each person suffers such bodily harm, sometimes more than once.More often, injuries are recorded in males of working age. The peak of injuries occurs during the warm season and the vacation period, when most are engaged in construction and repairs, work on personal plots, and actively resting in nature. The overwhelming majority of cases of subungual hemorrhage remain outside the field of vision of doctors, since patients often consider the damage to be insignificant and simply ignore it.

Subungual hematoma

Causes

Sharp directional impact. A contusion of the terminal phalanx, depending on the strength of the impact, can lead to damage to the vessels of the skin, crushing of tissues, the appearance of a laceration, and bone fracture.Each of these injuries is characterized by an accumulation of blood under the nail. Therefore, any injury requires medical attention.
Prolonged mechanical stress. Wearing shoes of the wrong size and fullness leads to injury to the nail plates and the skin beneath them. In fact, a callus develops, which fills with serous fluid or blood. In this case, the nail plate may peel off completely or partially.

Pathogenesis

Classification

Subungual bruise. It develops as a result of the impregnation of the skin and subcutaneous tissue with blood from damaged vessels.As a rule, it is formed with an insignificant effect and is characterized by unexpressed symptoms. The patient’s condition is quickly normalized, the functioning of the limb is restored.
Subungual hematoma. Differs from bruising by dissection of tissues with the formation of a cavity filled with blood. Hemorrhagic impregnation also takes place, however, the volume of blood poured out is much larger than with bruising, which increases the likelihood of nail detachment and the development of other complications.

Symptoms of the subungual hematoma

Complications

Diagnostics

General examination .A hematoma is indicated by the presence of a previous mechanical effect, an acute course with a rapid increase in symptoms. Palpation of the damaged area is painful. Drainage, which can be performed directly during the outpatient appointment, has a quick effect.
X-ray examination . An X-ray of a finger is performed to detect a violation of the integrity of the bones and joints of the limb. According to the X-ray data, it is possible to judge the presence of a fracture, but it is impossible to draw unambiguous conclusions about the degree of damage to soft tissues (skin, tendons, muscles), the volume of the hematoma.

Treatment of subungual hematoma

First aid. Proper care of the damaged phalanx allows you to quickly relieve pain, stop or slow down bleeding, and prevent detachment of the nail plate.Immediately after the injury, you must immerse your finger in a container of cold water for 15-20 minutes. Then, if there is an open wound, treat the damaged area with an antiseptic solution and apply a bandage.
Drainage of hematoma. The nail plate over the hematoma is punctured with a needle or burned out with a thermocoupler. The outflow of blood through a small hole leads to a decrease in pressure on the tissues, a decrease in the intensity of pain. A drained subungual hematoma dissolves faster, which is important for patients who need not have cosmetic defects on their hands.
Removal of the nail plate. The nail plate is removed partially or completely when it is detached from the nail bed. Attempts to save the nail can lead to unfavorable consequences: detached fragments disrupt the normal functioning of the finger, and can cause additional injury in case of accidental separation.
Surgical debridement. Crushing injury of tissues, laceration, bone fracture require PST, which includes removal of non-viable fragments, suturing, drainage.The purpose of medical manipulations is to create optimal conditions for healing, prevention of dysfunction of the foot or hand, and purulent-septic complications.
Whitening of damaged nail. The blood-soaked nail plate grows back within a few months. To eliminate a cosmetic defect in one procedure, the injection subungual injection of special bleaches allows. In this case, the black spot is completely discolored. Topically applied whitening drugs do not give a noticeable effect.

Forecast and prevention

90,000 Subungual hematoma – causes, symptoms, diagnosis and treatment

Subungual hematoma is a consequence of mechanical trauma to the nail phalanx of the upper or lower extremity, in which hemorrhage occurs in the soft tissues of the nail bed. The damage is characterized by pain of varying degrees of intensity, a local increase in temperature, edema, the appearance of red, and then bluish and black staining of the nail plate.Diagnosis is based on history and clinical presentation. In most cases, no treatment is required. Detachment of the nail plate, laceration of soft tissues is an indication for surgical treatment of the damaged area, suturing and dressing.

General information

Synonymous names are used to denote pathology: bruise under the nail, “blue nail”. Throughout life, each person suffers such bodily harm, sometimes more than once.More often, injuries are recorded in males of working age. The peak of injuries occurs during the warm season and the vacation period, when most are engaged in construction and repairs, work on personal plots, and actively resting in nature. The overwhelming majority of cases of subungual hemorrhage remain outside the field of vision of doctors, since patients often consider the damage to be insignificant and simply ignore it.

Subungual hematoma

Causes

Sharp directional impact. A contusion of the terminal phalanx, depending on the strength of the impact, can lead to damage to the vessels of the skin, crushing of tissues, the appearance of a laceration, and bone fracture.Each of these injuries is characterized by an accumulation of blood under the nail. Therefore, any injury requires medical attention.
Prolonged mechanical stress. Wearing shoes of the wrong size and fullness leads to injury to the nail plates and the skin beneath them. In fact, a callus develops, which fills with serous fluid or blood. In this case, the nail plate may peel off completely or partially.

Pathogenesis

Classification

Subungual bruise. It develops as a result of the impregnation of the skin and subcutaneous tissue with blood from damaged vessels.As a rule, it is formed with an insignificant effect and is characterized by unexpressed symptoms. The patient’s condition is quickly normalized, the functioning of the limb is restored.
Subungual hematoma. Differs from bruising by dissection of tissues with the formation of a cavity filled with blood. Hemorrhagic impregnation also takes place, however, the volume of blood poured out is much larger than with bruising, which increases the likelihood of nail detachment and the development of other complications.

Symptoms of the subungual hematoma

Complications

Diagnostics

General examination .A hematoma is indicated by the presence of a previous mechanical effect, an acute course with a rapid increase in symptoms. Palpation of the damaged area is painful. Drainage, which can be performed directly during the outpatient appointment, has a quick effect.
X-ray examination . An X-ray of a finger is performed to detect a violation of the integrity of the bones and joints of the limb. According to the X-ray data, it is possible to judge the presence of a fracture, but it is impossible to draw unambiguous conclusions about the degree of damage to soft tissues (skin, tendons, muscles), the volume of the hematoma.

Treatment of subungual hematoma

First aid. Proper care of the damaged phalanx allows you to quickly relieve pain, stop or slow down bleeding, and prevent detachment of the nail plate.Immediately after the injury, you must immerse your finger in a container of cold water for 15-20 minutes. Then, if there is an open wound, treat the damaged area with an antiseptic solution and apply a bandage.
Drainage of hematoma. The nail plate over the hematoma is punctured with a needle or burned out with a thermocoupler. The outflow of blood through a small hole leads to a decrease in pressure on the tissues, a decrease in the intensity of pain. A drained subungual hematoma dissolves faster, which is important for patients who need not have cosmetic defects on their hands.
Removal of the nail plate. The nail plate is removed partially or completely when it is detached from the nail bed. Attempts to save the nail can lead to unfavorable consequences: detached fragments disrupt the normal functioning of the finger, and can cause additional injury in case of accidental separation.
Surgical debridement. Crushing injury of tissues, laceration, bone fracture require PST, which includes removal of non-viable fragments, suturing, drainage.The purpose of medical manipulations is to create optimal conditions for healing, prevention of dysfunction of the foot or hand, and purulent-septic complications.
Whitening of damaged nail. The blood-soaked nail plate grows back within a few months. To eliminate a cosmetic defect in one procedure, the injection subungual injection of special bleaches allows. In this case, the black spot is completely discolored. Topically applied whitening drugs do not give a noticeable effect.

Forecast and prevention

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Subungual hematoma

Subungual hematoma or for hikers about the “sick”

All of us at some time, due to our carelessness, received a nail injury, be it a bruise or pinching.It is completely unexpected to find a blue toenail as a result of a long transition or a prolonged descent. This article is about what it is and how to deal with it.

Subungual hematoma – is formed as a result of pinching a finger or hitting with a heavy object. A hematoma can also occur in the absence of an obvious toe injury, for example, due to the fact that the forefoot, and therefore the nail, is tightly pressed against the hard toe of the shoe, which presses the nail.This is sometimes seen in skiers and runners.

Extremely painful pulsation occurs in the finger, the nail gradually turns completely or partially blue. In this case, unbearable pain can last for hours. It is caused by the increased pressure of the blood accumulated under the nail plate – the cavity is limited and there is nowhere for blood to go, there is a feeling of a bursting finger.

Treatment is very simple and gives quick results. The finger and nail must be treated with iodine.Warm up an unbent paper clip on a candle or an alcohol lamp and with a red-hot tip, immediately burn a dotted hole in the center of the hematoma in the nail. After which the blood flows out, often in a rather strong stream. A wet bandage applied after this manipulation provides some cooling, and also prevents overgrowing too quickly. The procedure is absolutely painless, there are no nerves in the nail. If the hematoma is not released in a timely manner, nail detachment cannot be avoided.

If you do not “burn”, and endure the pain for some time, then in a week or two the blue will disappear, the nail will become milky white and most likely, the nail will peel off.The nail may still stick around the edges, but there will be a cavity underneath. Six months later, a new one will grow on the site of the injured nail. With such injuries, local hypothermia (cold) relieves pain well – immerse your leg in cold water for a while. Try not to touch the damaged nail, in order to avoid infection and suppuration, it is recommended to put a bandage on the finger, I additionally used Vishnevsky’s ointment. You may have to keep your foot without shoes on the following days. At the first opportunity, it is better to contact the surgeon, although if everything is done correctly and the nail has ceased to bother you, you can do without going to the doctor’s office.

Later you can go to the clinic and remove the old nail, but this is not necessary, and the surface that is open after removal heals quite painfully. Try to fix the peeling nail, for example, with a plaster or a light bandage, so it will better protect and protect the nail bed from injury. There is no need to fear for the nail if there are no suppurations and blood accumulations anymore. The dried blood attaches to the nail and grows with it. Handle it very gently.Avoid pressure. As it grows back, trim the regrown toenail.

You can protect your feet by adhering to the following preventive measures :

1. Shoes – should be roomy enough so that there is enough room at the toes for some forward movement. Lace your shoes well, but do not overtighten your foot. Sneakers with solid toes are not suitable for hiking. In summer, it is good to have sandals with track soles in your outfit;

2.The appearance of a hematoma does not always depend on the nail length (it may be short, but convex) – it is still better to cut the nail shorter and make sure that the nails do not experience blows;

3. Do not be afraid in the heat of the comfortable and thick socks with the best cushioning . Oxygen is not required for nails and they do not evaporate moisture;

4. On the descent try to descend sideways – slowly, but without injuries.

Good luck!

Yarovaya I.I.
www.cliffhang.narod.ru

& nbsp

How to get rid of bruised nail pain?

Nail contusion can happen to anyone, and it is a fairly common injury to both hands and feet. But the degree of its severity can differ significantly. You can just pinch your finger, or maybe a heavy object will fall on it or someone steps on your foot – there are many traumatic situations and no one can be 100% insured against them.But what to do in such a situation, when not a single day is tormented by pain, you should know.

First, let’s look at the symptoms that can be observed with a bruised nail plate. At the first moment, if the blow was strong enough, a hemorrhage occurs under the plate and a hematoma is formed, which manifests itself in a color change to blue or even black. In the worst case, bruising can result in nail rejection. Here, it remains only to wait for the growth of a new one, and most likely it will be severely deformed.

A bruised injury is quite painful and these sensations can persist for a long time after. How to help the nail and how to calm the pain?

Sequence of actions for severe nail contusion

1. The first thing to do immediately after a bruise is to put the nail under a stream of cold water, this will help dissolve the accumulated blood. You can also immerse your finger in a container of ice for 5 minutes. If the pain persists, the procedure is repeated after 15 minutes.

2.The next step is to disinfect. The best option here would be to simply wipe the nail plate with a cotton swab dipped in iodine. If there is a likelihood of edema, then you can make an iodine mesh for the entire arm.

3. If the bruise was so severe that signs of nail rejection appear, then a pressure bandage should be applied or an adhesive plaster should be glued. Thus, it is not always possible to save the nail, but you can try.

4. If you feel severe throbbing pain – this is the action of a hematoma, and if nothing is done, then because of this, the nail will gradually rise and rejection is also possible.If blood appears during a bruise, it is worth squeezing it out before it dries. There is a good way to help the blood flow out from under the nail. To do this, take a paper clip and heat it up on a fire, and then it gently burns the nail, and thus a hole appears through which the blood comes out.