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10.07 Subungual Hematoma


Presentation

After a blow or crushing injury to the fingernail, the patient experiences severe and sometimes excruciating pain, that persists for hours, and may even be associated with a vaso-vagal response. The fingernail has an underlying deep blue-black discoloration which may be localized to the proximal portion of the nail or extend beneath its entire surface.

What to do:

What not to do:

Discussion:

The subungual hematoma is a space-occupying mass that produces pain secondary to increased pressure against the very sensitive nailbed and matrix. Given time, the tissues surrounding this collection of blood will stretch and deform until the pressure within this mass equilibrates. Within 24 hours the pain therefore subsides and, although the patient may continue to complain of pain with activity, performing a trephination at this time may not improve his discomfort to any significant extent and will expose the patient to the risk of infection. If you choose not to perform a trephination explain this to the patient who may be expecting to have his nail drained . There is some risk of missing a nail bed laceration under the hematoma, but, for most underlying lacerations, splinting by its own nail may be superior to suturing. When there are associated lacerations, open hemorrhage or broken nails, a digital block should probably be performed and the nail lifted up for inspection of the nailbed and repair of any lacerations. Keep in mind that not all dark patches under the nail are subungual hematomas. Consider the diagnosis of melanoma, Kaposi's sarcoma and other tumors when the history of trauma and the physical examination are not consistent with a simple subungual hematoma.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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