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Home | LITFL | Clinical Cases | Subungual haematoma trephination

Subungual haematoma trephination

by Dr Mike Cadogan, last update March 6, 2019

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

Subungual Haematoma Drainage 1

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


  • Subungual Haematoma trephination 01
    Half Moon Nail
  • Subungual Haematoma trephination 02
    Cautery preparation
  • Subungual Haematoma trephination 03
    Constant firm pressure
  • Subungual Haematoma trephination 04
    Gentle massage
  • Subungual Haematoma trephination 05
    Success

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
Subungual Haematoma drainage success
Most, but not all attempts to drain the subungual haematoma will be successful!!

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

CLINICAL CASES

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About Dr Mike Cadogan

Emergency physician | medical informatics | medical education/textbooks. Asynchronous learning #FOAMed evangelist. | @sandnsurf | LinkedIn

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