Subungual haematoma trephination

Following on from Bone and Joint Bamboozler 006 we outline a simple method for drainage of the Subungual haematoma

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Treatment options

Wait and See:

• Patients who are not experiencing significant pain at rest, should not have trephination performed, and can be treated with simple analgesia, rest, ice, and a protective splint.

Trephination:

• Trephination gives good cosmetic and functional result in both adults and children as long as no other fingertip injury is present.
• Trephination makes a closed wound open, and introduces the risk of bacteria entering causing infection, once procedure completed and haematoma evacuated no need to further soak digit, and a protective dressing should be applied for 7-10 to prevent infection.

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Trephination Methods:

Hot Cautery:

• This method involves applying a heated metal point to the nail, to relive the haematoma; this can be easy as heating paper clip, or using specially designed devices.
• Importantly this should not be done in a patient with acrylic nails. Acrylic nails are highly flammable and an alternate method should be chosen.

Drilling:

This involves using a specially designed drill or a wide bore needle to penetrate the nail to relive the haematoma.

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Hot Cautery Option

Points to consider:

• Ring blocks are generally not indicated, as once the pressure is released pain subsides considerably
• The digit needs to be soaked in antibacterial solution before attempting trephination to decrease bacterial load.
• Caution needs to be taken in order not to penetrate to far, and traumatise the nail bed.
• It’s generally not necessary to remove nail to inspect nail bed

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See one, do one…

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References

FOAMed references

• Guthrie K.  The Half Moon Nail. LITFL

Journal articles

• Bonisteel PS. Practice tips. Trephining subungual hematomas. Can Fam Physician. 2008 May;54(5):693.
• Akella A, Daniel AR, Gould MB, Mangal R, Ganti L. Subungual Hematoma. Cureus. 2023 Nov 17;15(11):e48952
• Blereau C, Radloff S, Grisham J. Up in flames: the safety of electrocautery trephination of subungual hematomas with acrylic nails. Western Journal of Emergency Medicine. 2022 Feb 23;23(2):183.

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