Subungual Hematoma (Bleeding Under Nail)

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Subungual Hematoma Facts

  • A subungual hematoma is a collection of blood in the space between the nail bed and fingernail.
  • Subungual hematomas result from a direct injury to the fingernail.
  • The pressure generated by this collection of blood under the nail causes intense pain.

Subungual Hematoma Causes

  • Subungual hematomas most commonly form after a crush-type injury to the tip of the finger or toe.
  • This injury can occur in many ways:
    • Hitting your finger with a hammer
    • Dropping a heavy object on your toe
    • Closing your finger in a door

Subungual Hematoma Symptoms and Signs

  • Blood underneath the nail of either a finger or toe is a subungual hematoma.
    • You will have a discoloration of red, maroon, or other dark color beneath the nail after an injury.
  • The most common symptom is intense pain.
    • Pressure generated between the nail and the nail bed, where the blood collects, causes this pain.
    • The pain may also be caused by other injuries such as a fracture (break) to the underlying bone, a cut in the nail bed, or bruising to the finger or toe itself.

When to Seek Medical Care for a Subungual Hematoma

If the pain is mild and the hematoma (blood collection) is less than 25% of the area under the nail, then home care can be considered.

If the hematoma is 50% or more of the underlying nail area, then medical attention is required.

If the injury that causes the subungual hematoma is severe enough to cause intense pain and tenderness, you should seek medical attention. The mechanism of injury for this condition can cause a fracture to the bone at the end of the finger or toe or a laceration to the nail bed under the nail that may require further medical attention.

Subungual Hematoma Diagnosis

  • X-ray
    • Often, an X-ray is taken to look for a fracture (break) to the underlying bone.
    • X-rays do not provide any information regarding the bleeding or hematoma formation underneath the nail.
  • Nail bed evaluation
    • Depending on the type of injury and the degree of the injury and how much blood forms under the nail, the doctor may decide to remove the nail to check the nail bed for lacerations (cuts). While it used to be customary to have the nail removed to examine the nail bed for lacerations or injuries, this is no longer routine practice if the nail edges or margins are intact.

Subungual Hematoma Home Remedies

  • Ice, elevation (keeping your arm or leg above the level of your heart), and pain medications are recommended for minor hematomas. Wrap ice in a towel and do not apply ice directly to skin. A bag of frozen vegetables (corn or peas) wrapped in a towel works well.
  • If the hematoma involves more than 50% of the area of the nail, then medical attention is needed.
  • If the nail was removed by the injury and the nail bed wasn't cut, the following home treatment is recommended until the nail bed begins to be less sensitive, usually in seven to 10 days.
    • Twice daily soaks with antibacterial soap and water for 10-15 minutes
    • After soaks, apply a dry, sterile bandage (Band-Aid)

Treatment for Subungual Hematoma

  • Several techniques are used to drain the blood beneath the nail. This procedure is also called releasing the hematoma or trephination.
    • No single technique is preferred.
    • How your hematoma is drained depends on the experience of the doctor and where it is done.
  • Occasionally, the finger or toe is numbed with a digital block. (Your fingers and toes are called digits.) Some doctors (health care professionals) opt not to numb up the digits as the injection itself can cause as much if not more pain than the actual drainage of the hematoma.
    • A numbing medication such as lidocaine is injected at the bottom of your finger or toe.
    • Injecting the medication here numbs the entire digit.
    • As soon as your finger or toe is numb, the procedure can take place.
  • The following are commonly used methods for draining your hematoma:
    • Cautery: A battery-operated device is used to burn a hole in the nail until the blood is reached and drains out of the hole. This technique should not be used if the patient is wearing artificial acrylic nails which might be flammable.
    • Needle: A large diameter needle is used to drill or bore into the nail to create a hole to allow the blood to drain out.
    • Paper clip: This technique, although an older one, is still used by some practitioners. A paper clip is opened so that the pointed end is free. Then the pointed end is heated up, usually by passing it through a flame, and used to burn through the nail. This technique uses a combination of the cautery method and the needle method.

Subungual Hematoma Follow-up

  • After the subungual hematoma has been drained, follow-up is usually not necessary.
  • Antibiotics are not routinely needed after a subungual hematoma is drained.
  • If the nail was removed and a cut in your nail bed was stitched closed, you should see your doctor in 48-72 hours for re-examination.
    • Usually, the type of sutures (stitches) placed will dissolve, so removal is not needed.
    • If non-dissolvable sutures (nylon) are placed in a nail bed laceration, they need to be removed in about seven days in the emergency department or by your doctor.
    • Close monitoring is still recommended.

Subungual Hematoma Prevention

Use common sense and practice other safety-minded actions to prevent getting your fingers slammed in doors or dropping heavy objects on your toes.

  • Steel-toed shoes are important safety equipment to wear on certain high-risk jobs such as construction.
  • Watch children's hands as you open and close car doors.
  • Give your full attention to the task at hand. Finger injuries often happen when the person using the tool is distracted.
  • Don't lift something you cannot handle alone. Find people to help you carry heavy objects to avoid dropping them on your toes.

Subungual Hematoma Prognosis

  • After the subungual hematoma is drained, the pressure beneath the nail is relieved, and the pain decreases significantly.
  • The hole formed in the nail will remain and grow out at the rate that the nail normally grows.
  • One possible risk and long-term complication of a subungual hematoma is a nail bed laceration (cut).
    • If trauma is severe (for example, an subungual hematoma of the surrounding soft tissue including the nail and nail bed), the nail bed laceration can be stitched closed after the nail is partially or completely removed.
    • If the skin beneath the nail is lacerated, similar to any other skin cut, it may not heal properly.
    • This complication can result in deformity of the nail and the nail growth.
    • The deformity may be temporary and go away after the nail grows out, or it may be permanent, and you may have an obviously deformed nail forever.
    • If you do not seek medical attention at all for a subungual hematoma (not recommended), and sometimes even if you do, and a significant injury occurs under the nail, the nail may completely fall off as it grows out as part of the natural healing process.
    • Despite best efforts by doctors and yourself at home, nail deformity and permanent abnormalities can result from such injuries.

Subungual Hematoma Pictures

A thumb after it was hit with a large hammer. Notice that the dark discoloration beneath the nail takes up more than 75% of the area. This is blood. This hematoma required drainage to relieve the pressure.
A thumb after it was hit with a large hammer. Notice that the dark discoloration beneath the nail takes up more than 75% of the area. This is blood. This hematoma required drainage to relieve the pressure. Click to view larger image.

The battery-operated cautery unit and its tip when it is activated. Notice the red hot area used to burn the hole in the nail.
The battery-operated cautery unit and its tip when it is activated. Notice the red hot area used to burn the hole in the nail.Click to view larger image.

The process of burning a hole in the nail to relieve the hematoma. Notice the blood draining from the hole after the hole was formed with the cautery unit's hot tip. The finger has been numbed prior to this procedure.
The process of burning a hole in the nail to relieve the hematoma. Notice the blood draining from the hole after the hole was formed with the cautery unit's hot tip. The finger has been numbed prior to this procedure. Click to view larger image.

The same thumb after it has been drained. Notice the hole in the nail and the blood draining from the hole. The large dark area beneath the nail (the hematoma) is practically gone.
The same thumb after it has been drained. Notice the hole in the nail and the blood draining from the hole. The large dark area beneath the nail (the hematoma) is practically gone. Click to view larger image.

An example of a nail with a subungual hematoma that occupies less than 25% of the nail area. This hematoma did not require drainage.
An example of a nail with a subungual hematoma that occupies less than 25% of the nail area. This hematoma did not require drainage. Click to view larger image.

The same subungual hematoma three-and-one-half weeks after the original injury.
The same subungual hematoma three-and-one-half weeks after the original injury. Click to view larger image.

A paperclip opened for use in draining a subungual hematoma. The open end would be heated to allow it to make a hole in the nail.
A paperclip opened for use in draining a subungual hematoma. The open end would be heated to allow it to make a hole in the nail. Click to view larger image.

Treatment of an Uncomplicated Subungual Hematoma

A painless and small subungual hematoma usually requires no treatment. However, the pressure generated by pooled blood under the nail can be extremely painful. To relieve the pain, doctors perform decompression, also called trephination, which allows the underlying blood to drain, relieving pressure and pain to the area.

After numbing the affected finger or toe with a nerve block, doctors commonly use several decompression methods to drain a subungual hematoma:

  • Cautery. A heated wire (electrocautery device) is used to burn the hole or holes during a painless procedure that takes only a few seconds.
  • Paper-clip method. A heated paper clip is placed over the center of the hematoma to melt a hole into the nail.
  • Needle. A large-diameter needle is used to perforate the nail.

SOURCE: WebMD Medical Reference

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Reviewed on 11/20/2017
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