II. Pathophysiology

  1. Bleeding develops between nail and phalanx

III. Causes

  1. Crush injury to nail

IV. Symptoms

  1. Severe, throbbing digital pain

V. Signs

  1. Discoloration of nail
  2. Tip of digit swollen and tender

VI. Associated conditions

VII. Imaging

  1. XRay AP, lateral and Oblique XRay of digit
    1. Indicated for Subungual Hematoma involving >50% of the nail bed
    2. Assess for distal Tuft Fracture

VIII. Management: Drainage (Nail Trephination)

  1. Contraindications
    1. Phalanx Fracture
    2. Nail Bed Laceration
    3. Large Subungual Hematomas (>50% of nail)
      1. Requires Nail Bed Laceration suturing (see exception below)
  2. Technique
    1. Precaution
      1. Avoid lunula (and underlying nail matrix)
    2. Gently drill 2-3 small holes into nail
      1. Number 11 blade or
      2. Spin 18 gauge needle between fingers or
      3. Heated paper clip
    3. Splint fingertip (e.g. AlumaFoam Splint)
      1. Apply for up to 3 days until pain subsides

IX. Management: Large Subungual Hematoma (>50%)

  1. Standard teaching is to remove nail, repair Nail Bed Laceration, and replace nail
  2. Study demonstrated no benefit in children to nail bed repair over trephination in large Subungual Hematoma
    1. Roser (1999) J Hand Surg Am 24(6): 1166-70 +PMID:10584937 [PubMed]

X. References

  1. Brandenburg (1996) Consultant p.331-340
  2. Calmbach (1996) Lecture in Minneapolis
  3. Dvorak (1996) Lecture in Minneapolis
  4. Lillegard (1996) Lecture in Minneapolis
  5. Lin, Gajendran and Orman in Herbert (2016) EM:Rap 16(11): 7-8
  6. Wang (2001) Am Fam Physician 63(10):1961-66 [PubMed]

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