aka Bone and Joint Bamboozler 006
40 year old male attends with acutely painful toe following a weekend DIY incident:
[Sledgehammer 1 – Man 0]
What is the diagnosis?
- Subungual Haematoma
- Subungual haematomas occur when there is bleeding beneath the nail.
- Generally caused traumatically by getting it caught between to hard surfaces.
- The haematoma becomes trapped between the rigid structures of the nail above and the distal phalanx below.
- The space occupying mass causes intense pain secondary to increased pressure against the very sensitive nail bed and matrix.
How would you assess this injury?
Examination should include:
- Testing extensor and flexor tendons
- Testing circulation by capillary refill
- Checking the sensitivity to the area
- X-rays are generally indicated to rule out crush injury or fracture to the distal phalanx
Document the percentage of nail bed covered by the haematoma, surrounding damage to tissues, nailbed, and nail margins.
What are the potential complications?
- Fracture to the distal phalanx
- Crush injury
- Nail bed injury
- Performing trephination on subungual ecchymosis.
- If no history of trauma or story doesn’t fit with subungual haematoma consider melanoma, Kaposi’s sarcoma, and other tumors.
What are the 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 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.
- 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.
- This involves using a specially designed drill or a wide bore needle to penetrate the nail to relive the haematoma.
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
LITFL Further Reading