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Subungual Hematoma

  • Subungual hematoma is a localized collection of blood between the nail and nail bed of a finger or toe that results from an injury or laceration of the soft tissue of the nail bed under an intact nail.
  • Pressure of the hematoma against the periosteum of the distal phalanx produces severe pain.
  • Classification of the injury to the underlying nail bed tissue:
    • Simple laceration
    • Stellate laceration
    • Crush injury
  • Older children and young adults are the most commonly affected individuals.
  • One of the most common hand injuries seen in the office or emergency room
  • The long finger is most frequently injured of all of the digits because of its prominence.
  • Blunt trauma to the distal phalanx causes this condition.
  • Injury in a door is the most common mechanism, followed by smashing between 2 objects and injury by a saw.
Associated Conditions
Distal phalanx fracture
Signs and Symptoms
  • Typically, in an acute injury, the patient complains of localized pain and gives a history of trauma to the finger or toe.
  • Nail deformity is a late sign of a neglected nail bed injury.
Physical Exam
  • On inspection, the hematoma is visible through the nail.
  • If an underlying fracture of the distal phalanx is present, diffuse swelling of the digit tip is seen.
Plain films of the affected digit should be obtained to rule out an associated fracture of the distal phalanx.
Differential Diagnosis
  • Contusion or fracture of the distal phalanx without hematoma formation
  • Subungual melanoma, if history of injury is not clear
  • Pyogenic granuloma at base of the nail, usually caused by perforation with cuticle scissors
General Measures
  • Treatment for a painful subungual hematoma involving <50% of the nail bed :
    • Prepare the nail in sterile fashion before the procedure .
    • It is not necessary to anesthetize the finger.
    • Drain the hematoma by trephining 3 holes in the nail over the affected area with a battery-powered cautery such as an ophthalmic cautery (preferred method), a heated paper clip, or a 16-gauge needle, while the patient presses the pad of the finger firmly against a hard surface.
    • Drainage provides prompt relief of pain.
  • Treatment for a hematoma involving >50% of the nail bed or with an underlying fracture:
    • Remove the nail to inspect and repair the underlying nail bed injury.
    • For an underlying fracture:
      • Splint the distal phalanx in addition to replacing the nail.
      • A displaced fracture may require reduction and fixation.

The patient may continue activity as tolerated.

Special Therapy
Physical Therapy

A hand therapist can fashion a tip protector to wear until the end of the finger is less sensitive.
  • Prescribe NSAIDs for pain relief.
  • Prophylactic antibiotics should be given.
  • Surgical repair of a nail bed laceration requires nail removal.
    • Use a digital nerve block to obtain adequate regional anesthesia.
    • Grasp the distal edge of the nail with a clamp and bluntly dissect the nail from the nail bed and eponychium.
    • After irrigation, repair the laceration with fine absorbable sutures (e.g., 6-0 or 7-0 chromic).
    • Splint the eponychial fold to prevent formation of adhesions, which can result in deformity of the regrown nail.
      • Use the proximal part of the removed nail or a piece of heavy foil (suture wrapper) as a splint.
      • The replaced nail may be sutured to the eponychium with 5-0 nylon.
      • Cover the exposed nail bed with petrolatum gauze and apply a tubular gauze dressing.

The prognosis is excellent, if proper assessment and treatment are performed.
  • Nail deformity (i.e., fissured nail) if the eponychial fold is not properly splinted after removal of the nail or if a nail bed laceration is not repaired
  • Split or nonadherent nail
  • Osteomyelitis, a complication of unsterile drainage of the hematoma and improper wound dressing
Patient Monitoring

The patient should be given a follow-up appointment within 1 week if nail bed repair has been performed.

Patient Teaching
Patient should be counseled about signs of infection.
  • Late deformity of the nail is difficult to reconstruct, and the results are unpredictable.
  • Therefore, guidelines given earlier for inspecting and repairing nail bed injury should be followed to minimize the risk of late deformity.
Q: How is the pain associated with subungual hematoma addressed?
A: The pain is secondary to the pressure of blood in this confined space, and evacuation of the hematoma is indicated to relieve the pain. The finger is prepped with Betadine, and a battery-powered microcautery tip is used to burn a hole through the nail.
Q: Is nail removal and nail bed repair always indicated in subungual hematoma?
A: Nail removal and nail bed repair are considered if >50% of the nail is undermined by blood and the nail is broken or the nail edges are disrupted.

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