Subungual Hematoma Evacuation

CHAPTER 35 Subungual Hematoma Evacuation



Rebecca Beach


Injuries to the nail bed and fingertip are the most common injuries to the upper extremity. Most common among these is a subungual hematoma, which results from a direct blow to the fingernail or a squeezing-type injury to the distal finger, causing bleeding into the space between the nail bed and the fingernail itself. Intense pain can result from the pressure generated by such a hematoma. Evacuation of the hematoma can produce significant relief and can be performed safely in the outpatient setting. Toenails can be treated in the same fashion. Evacuation of a hematoma may or may not prevent the eventual spontaneous avulsion of the nail that results from some hematomas. Patients should be made aware of this possibility. Radiographs may be necessary and, if a fracture is documented, antibiotics may be indicated because this would then essentially be an open fracture.



Indication


A visible, painful hematoma beneath the involved nail (Fig. 35-1) requires treatment.


image

Figure 35-1 Subungual hematoma.



Contraindications



• Crushed or fractured nail bed or fracture of distal phalanx.

• Hematomas involving greater than 50% of the nail may indicate laceration of the underlying nail bed. (Removal of the nail and repair of the laceration is recommended by some experts to avoid a post-traumatic nail deformity. Others recommend leaving the nail in place as a splint. The patient should be warned that the nail may be deformed unless the nail bed is examined and treated.)


Equipment



• Alcohol lamp or Bunsen burner (or cigarette lighter), metal paperclip, and forceps or hemostat

• Or battery-operated cautery unit

• Or 18-gauge needle or no. 11 scalpel

• Or automatic drill device (Dremel tool, dental burr, or PathFormer device)

• Or radiofrequency or electrocautery unit with needle or pointed electrode


Technique



1 Wash the digit as thoroughly as possible with an antibacterial soap to decrease the possibility of contamination of the hematoma and subsequent infection.

2 Consider a digital block with lidocaine without epinephrine because any pressure on the area can be painful.

3 Create a hole in the nail directly over the center of the hematoma to allow decompression.
• Paperclip method. Partially straighten a metal paperclip, grasp it with the forceps, and heat it over the alcohol lamp, Bunsen burner, or lighter. Place the heated clip firmly on the nail, allowing it to melt the tissue for a few seconds until the nail is completely perforated (Fig. 35-2).

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Subungual Hematoma Evacuation

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