Subungual haematoma trephination

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

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.

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.

Drilling:

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

Hot Cautery Option

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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

See one, do one…

References

• Bonistereel, P. (2008). Trephining subungual hematomas.  Canadian Family physician. 54, 693.
• Guthrie K.  The Half Moon Nail. LITFL
• Sherman, S. Simon’s Emergency Orthopedics 7e
• Purcell, D. Minor Injuries A Clinical Guide 3e