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Subungual Hematoma
From WikiSM
Contents
Other Names
- Nail blister
- Fingernail blister
- Toenail blister
- Acute Traumatic Subungual Hematoma
Background
- This page refers to a painful hematoma underneath the fingernail or toenail
Pathophysiology
- General
- Definition: blood that is trapped under the nail after trauma
- Can occur in either fingers or toes
- Occurs after either acute trauma, typically a crush injury
- Types
- Simple: the nail and nail fold are intact
- Complex: accompanied by significant injuries to the nail fold and digit
Etiology
- Trauma, examples include
- Crush in car door
- Stubbing one's toe
- Subsequently, there is bleeding under the nail
- Leads to formation of subungual hematoma
Associated Conditions
- Phalanx Fractures (Hand)
- One study found 1/3 of patients had associated distal phalanx fractures, nailbed lacerations[1]
- Phalanx Fracture Foot
Pathoanatomy
Risk Factors
- Unknown
Differential Diagnosis
- Fractures
- Dislocations
- Tendinopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Nail Bed Injuries
- Pediatric Considerations
- Other
Clinical Features
- History
- Patients will describe some form of trauma
- Throbbing pain of the digit
- Often red, black or blue discoloration under the nail
- Physical Exam Physical Examination Hand
- Evaluate for nailbed injuries, deformities, loss of flexion or extension
- Typically will have dark or purple discoloration under the nail of the affected digit
- Patient may be tender in the same distribution
Evaluation
Radiographs
- Standard Radiographs Foot
- The diagnosis is clinical
- Radiographs useful to exclude associated fractures
Classification
- N/A
Management
Nonoperative
- Indications
- Vast majority of cases
- Intact or minimal disruption to nail fold, nail and phalanx
- Most cases can be managed by emergency medicine or primary care physicians
- Indications for referral to sub specialist
- Displaced fractures
- Intraarticular fractures
- Extensive nail bed injury
- Infected wounds
- No treatment
- Can strongly be considered if patient or athlete has no symptoms
- Analgesics
- Includes NSAIDS, Acetaminophen
- Can consider Digital Block if pain is significant
- Nail Trephination (decompression)
- Indications: if <50% of nail involved, < 24-48 hours old, symptomatic
- Contraindications: patients with obvious deformity, nail avulsion, >48 hours old
- Use electro-cautery or 18-gauge needle
- For most patients, this provides immediate relief of pain
- Nail Removal, drainage and nail bed repair
- Indications: associated nailbed avulsion, complex laceration, fingertip or toe avulsion
- Not routinely indicated if nail, nail fold intact
- Can be considered if >50% of nail is involved, although this is controversial
- Not required if fracture is present (controversial?)
- Requires Digital Block
- Consider antibiotics in
- Patients with tuft fracture
- High risk patients (diabetes, immunocompromised, etc) with any open fracture
- Salter-Harris fracture (Seymour fracture)
- Tetanus Prophylaxis as indicated
- In the setting of repetitive microtrauma, proper footwear can help decrease recurrence
Operative
- Indications
- Not routinely necessary unless co-occurring injury (i.e. fracture, nailbed laceration)
- Procedure
- Nailbed removal and exploration
- Laceration repair
Rehab and Return to Play
Rehabilitation
- Generally, no rehabilitation is required
Return to Play/ Work
- Players can typically return to play immediately
Complications and Prognosis
Prognosis
- Overall outcomes
- About 2/3 of patients report excellent or very good outcomes after trephination[2]
- Financial implications
- Significantly higher costs associated with nail removal and nail bed exploration[3]
- Size of hematoma
- Complications
- More likely to occur if there is a delay in care[6]
Complications
- Poor nailbed cosmesis
- Including deformity, loss
- Onycholysis (separation of the nail plate from the nail bed)
- Infection
- No apparent correlation between size of hematoma and risk of infection (need citation)
See Also
External
- Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. 1987 Jul;5(4):302-4.
- ↑ Meek S, White M. Subungual haematomas: is simple trephining enough? J Accid Emerg Med. 1998 Jul;15(4):269-71.
- ↑ Roser SE, Gellman H, Comparison of nail bed repair versus nail trephination for subungual hematomas in children, J Hand Surg 24(6):1166�1170, 1999.
- ↑ Roser SE, 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.
- ↑ Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: a prospective study. Am J Emerg Med. 1991 May;9(3):209-10.
- ↑ Chung S. Minor lesions. In: Textbook of Pediatric Emergency Medicine, 7th edition, Shaw KN, Bachur RG (Eds), Wolters Kluwer, Philadelphia 2016. p.1362.
Created by:
John Kiel on 1 September 2019 22:04:37
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Last edited:
16 October 2022 00:23:07
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