Overview of Subungual Hematoma Drainage
A subungual hematoma is a condition where blood collects under the nail due to an injury. People usually experience pain and color change of the nail as a result. It commonly happens when the fingertip gets a hard knock or is squeezed really hard, like when getting a finger pinched in a doorway. The pain is because the collected blood puts pressure on the nail bed. Sometimes this condition might include fractures in the small bone of the fingertip, complete or partial removal of the nail, or the tearing off a part of the fingertip. Fortunately, most subungual hematomas can be treated by making a small hole in the nail to relieve the painful pressure caused by the collected blood.
Physical Exam
Your doctor should check the whole nail for any damage and the entire finger to see how well it moves, feels touch and if blood is circulating properly. The doctor might hold your middle finger bone and test if you can resist when they try to bend the tip of your finger. Being weaker on the injured side may suggest a particular type of finger injury called a mallet finger. Checking how quickly blood returns after pressure is taken off the tip of your finger is one way to assess if blood is circulating amply after the injury. Especially with little kids, there might be a need for the doctor to numb the finger to give it a thorough check-up.
Tests
You may need to get a three-view X-ray to check for a possible fracture. It’s common for the tip of the small bone at the end of the finger to get fractured. Your doctor can also use a point-of-care ultrasound to see if there’s a tear in the nail bed or a fracture at the tip of the small bone at the end of the finger, which may call for a more involved repair process.
Anatomy and Physiology of Subungual Hematoma Drainage
The complete structure of a fingernail or toenail is known as the perionychium. This is made up of different parts including the nail fold (the skin frame around your nail), the paronychium (the skin at the tip of your finger), and the hyponychium (the hardened end section of the nail bed touching the skin at the tip of the finger).
Another part of the structure is the nail bed, which is made of the germinal and sterile matrices. The germinal matrix is located beneath the proximal nail fold – the part of your nail that is under the skin at the base of your nail. This matrix produces 90% of the cells that make up the nail. This area extends to the lunula, which is the half-moon shaped lighter section at the base of the nail.
The sterile matrix is found under the distal nail bed – at the end of your nail opposite the cuticle, and is rich in blood vessels. This part contributes to the layers of cells that help attach the nail to the nail bed.
Why do People Need Subungual Hematoma Drainage
If you have a bruise or bleed under your nail (known as a subungual hematoma) that is less than two days old, the current recommended treatment involves creating a small hole in the nail to drain the blood – a procedure called ‘trephination’. In the past, the advice was to remove the nail if the bruised or bleeding area was more than half the nail, or more than a quarter of the nail if a bone was broken. But now, research has shown that treating with trephination works equally well in most cases. It has similar levels of satisfaction with how the nail looks afterwards and has similar rates of potential issues.
When a Person Should Avoid Subungual Hematoma Drainage
There aren’t any strict reasons why a person should not have a process called trephination, which is a way of relieving pressure from a swelling. However, in some situations, it might be better for the look of your fingernail if a doctor also removes and repairs the nail. This may be the case if there’s a severe bruise under the nail that has caused the nail itself to lift off, if there’s a broken fingertip bone that’s moved out of place, or if there’s a fracture near the area where new nail cells grow.
If the bruise under the nail wasn’t caused by an injury (for example, if it’s been caused by different kinds of tumors such as a junctional nevus, melanoma, or splinter hemorrhages), trephination might not be helpful. In these cases, doctors might suggest a different plan.
Equipment used for Subungual Hematoma Drainage
The following are the supplies that will be used:
* Safety equipment: This includes a face mask with an eye shield and gloves to prevent the spread of germs.
* Numbing the area: A thin needle (25-gauge), a small syringe (3-ml), a drug to numb the area (1% lidocaine), a skin cleaner (topical antiseptic), and a bandage-type material (gauze).
* Making a small hole to relieve pressure (Trephination): This could be done with an electrical device that burns through skin (Electrocautery device) or a thick needle (18-gauge).
If no other tools are available, a heated paperclip could be used as a last resort.
Preparing for Subungual Hematoma Drainage
Before starting the procedure, the doctor will clean your finger with a special solution, usually chlorhexidine or povidone/iodine. This helps to prevent any germs from causing an infection during the procedure.
If you have a fracture at the tip of your finger, your doctor might suggest a local anesthetic injection, also known as a ‘digital block’, to numb the area and make the procedure less painful for you. However, sometimes this injection can be more painful than the procedure itself.
It’s important that your doctor explains the procedure and possible outcomes to you, and that you give your consent before starting. Your doctor will let you know that it’s normal to bleed from the site of the procedure, and also discuss possible complications which may include loss of the nail, the possibility of the blood clot (hematoma) forming again, and infection.
How is Subungual Hematoma Drainage performed
If you have a pool of blood beneath your fingernail or toenail (also known as a hematoma), your doctor might use one of three methods to relieve the pressure and pain. This procedure is called trephination.
In the first method, your doctor might use a handheld device called an electrocautery. It’s used to create a small hole in your nail over the spot where the blood is collected. To remove the blood, they might use a small glass tube.
In the second method, your doctor may use a needle to create a hole. They’ll place the needle at a 90-degree angle over the pool of blood and rotate it, like they are drilling a hole. Smaller needles might be used for children. If a smaller needle is used, your doctor might need to make several holes to provide relief.
If neither of these tools are available, a paperclip could be used as a last resort. They would heat the paperclip over a flame until it’s red hot, then gently touch it to the nail to burn a small hole. This would also be done over the area where the blood is pooled.
Once a hole is made, blood is expected to drain out from the pool beneath the nail, relieving most of your pain. The procedure may need to be repeated more than once to completely drain the blood. Your doctor will be careful to avoid damaging the skin beneath the nail during this procedure. Afterward, they’ll bandage the area with a clean dressing and advise you to keep it clean and dry.
Possible Complications of Subungual Hematoma Drainage
After treatment, patients should avoid immersing their finger in water because this can introduce bacteria into the area. It’s normal if a little blood comes out from the hole in the nail for one to two days. If you notice signs of infection like warmth, redness, more swelling, a fever, or if the pooled blood under the skin (hematoma) comes back with pain, please return for more medical attention right away.
If the bone at the tip of your finger (distal phalanx) is fractured without any shifting in the bone’s alignment (non-displaced), it should be put in a straight (extension) splint for 4 weeks. After this, you should check back with a hand specialist. The blood under the skin (hematoma) should slowly move towards the tip of your nail over the next few weeks.
If it doesn’t, you should go to a skin doctor (dermatologist) because this might suggest unusual tissue growth, potentially from something like a skin growth (nevus) or skin cancer (melanoma). Current medical opinion is undecided about whether or not to use antibiotics after the procedure. As it stands, they are usually not given because a small study found they didn’t help.
What Else Should I Know About Subungual Hematoma Drainage?
Injuries like this one are commonly reported among both children and adults. They can also occur in harsh environments. Several different methods, including simpler, less advanced ones, can help to treat these injuries quickly and effectively.