The patient will have had a crushing injury over the
fingernail; getting it caught between two heavy objects for
example, or striking it with a hammer. The pain is initially
intense, but rapidly subsides over the first half hour, and
by the time he is examined only mild pain and sensitivity
may remain. There is a light brown or light blue-brown
discoloration beneath the nail.
What to do:
Get an x ray to rule out a possible fracture of the distal
phalangeal tuft.
Apply a protective fingertip splint, if necessary for
comfort.
Explain that you are not drilling a hole in the patient's
nail, because there is not a subungual hematoma to
evacuate. Inform the patient that, in time, he may lose
the fingernail, but that a new nail will replace it.
What not to do:
Do not perform a trephination of the nail.
Discussion:
Unlike the painful space-occupying subungual hematoma, the
subungual ecchymosis only represents a thin extravasation of
blood beneath the nail or a mild separation of the nail from
the nailbed. Doing a trephination will not relieve any
pressure or pain, and may indeed cause excruciating pain, as
well as open this space to possi ble infection. The
patient's familiarity with nail trephination (above) may
give him the erroneous expectation that he should have his
nail drilled.
