Subungual Hematoma

What is a subungual hematoma? This is an injury that causes bleeding to occur under a toenail or fingernail bed. It usually occurs from blunt force trauma. The current medical standard is that if the blood takes up more that 25% of the nail bed then it should be released. In order to perform the procedure the injury should be less that 48 hours. Once the blood coagulates treatment no longer provides a beneficial outcome. Basically a hole is made in the affected toe and the blood comes flowing out relieving the pressure.

For the most part subungual hematomas are benign, however the larger they are the more likely a complication can occur. What are the complications, you ask? Well, due to the tremendous pressure as the new nail forms it will be deformed and its growth may be stunted or not occur at all. Also there is a greater chance or infection with the larger hematomas. 

I have had a few opportunities to treat patients with this type of injury. A couple of times in the ER and today in the office. an 8 y/o female, african american patient presented complaining of a subungual hematoma in her right had in the thumb. The hematoma was the result of getting her thumb shut in a car door the evening before. It was determined to involve approximately 60% of the nail bed. The pain was stated to be 8/10 and the patient had not slept at all the previous night due to the pulsatile pain. The patient failed over the counter analgesics administered by her mother. After close examination it was determined that the best course of treatment would be to make a hole in the nail bed to release the blood and relieve the pressure. I used an electric cautery device to burn a hole in the nail bed. The initial sting from this procedure is very painful but once the blood is released the patients pain from the pressure is relieved and they usually say that the pain from the procedure was well worth it as the pain relief from the release of the blood is amazing. 

1 thing that I like about this procedure is that as soon as you burn through the nail the blood bursts out like lava from a volcano. There is so much pressure that the blood explodes out. In fact blood splattered all over my white coat today as I performed the procedure. The patient was very brave but let out a horrendous cry as I made the hole in her nail. About 10 minutes post procedure all of her pain was relieved and I have a good feeling that she is going to sleep just fine tonight. Her mom was very happy especially when we told her that her daughter has a much better chance now of a normal nail re-growing.