Subungual Hematoma

Trephination: To create a fistula through the nail to the hematoma

Decompression, drainage, and pain relief of small subungual hematomas

Nail removal and nail bed laceration repair

Large hematomas and nail bed lacerations

Partial nail avulsion or subluxation with nail instability or nail fold disruption

CONTRAINDICATIONS

Significant crush injuries or missing/destroyed nail matrix warrant specialty consultation

RISKS/CONSENT ISSUES

Germinal matrix injuries and open tuft fractures should be documented and referred to a specialist to ensure optimal outcome

LANDMARKS

Hematomas typically collect on the sterile matrix under the nail

Germinal matrix

Region where new nail is formed

Avoid injury during the procedure

General Basic Steps

X-ray digit if fracture possible

Prepare patient

Consider anesthesia

Perform procedure (FIGURE 73.1)

Trephination

Goal is to form a hole through the nail of sufficient size to drain the hematoma

Personal protection (including an eye shield) as blood may spurt out when released

Needle or scalpel method: Apply gentle pressure with the tip of the instrument perpendicular to the surface of the nail, twisting until blood is released

Heated paper clip method: Creates a wider hole but may tattoo the nail bed

Disposable electrocautery device method: Quick and effective (FIGURE 73.2)

Discharge instructions are to soak the finger in warm water twice a day for 7 days to allow the blood to continue to drain

Nail Bed Laceration Repair

Supplies: Iris scissors, hemostats, and suture set with fine absorbable sutures (5-0 to 7-0 chromic or Vicryl)

Perform digital block under sterile conditions

Apply tourniquet for hemostasis

Remove the nail from the nail bed matrix

Insert closed Iris scissors horizontally under the nail

Gently spread scissors and advance in repeated movements, gradually progressing to the nail root and separating the entire nail from the nail bed

Once the nail is free from the nail bed and eponychium, grasp with hemostat and gently pull longitudinally to free the nail

FIGURE 73.1 Anatomy of the finger and nail bed. (From Eberlein R. Hand and finger injuries. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1048, with permission.)

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