When is treatment of subungual hematoma nailbed injuries indicated?

Updated: Sep 27, 2017
  • Author: Darrell Sutijono, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Small (less than 25% of the nailbed) and painless subungual hematomas require no intervention, as the hematoma will eventually reabsorb. If the subungual hematoma covers more than 25% of the nailbed or is causing pain, the patient should be offered evacuation via trephination or nail removal (see Hand, Subungual Hematoma Drainage).

Treatment of subungual hematomas covering greater than 25-50% of the nail bed is controversial and varies with personal preference. [18]  Historically treatment includes removal of the nail and repair of any underlying lacerations. This practice came about because 50% of these hematomas have concurrent nailbed lacerations. The incidence of nailbed laceration increases to 94% when associated with a distal phalangeal fracture, regardless of the size of the hematoma. [4, 19, 20, 21, 22]

More recent studies have concluded that as long as the nail is still partially adherent to the nailbed or paronychia and is not displaced out of the nail fold, removal of the nail and repair of the nailbed does not improve outcomes versus simple trephination. Neither the size of the hematoma nor the presence of an associated fracture has been associated with adverse outcomes. [15, 23, 24] Trephination is contraindicated if a fracture requires surgical repair or if the germinal matrix is entrapped within the fracture, as delayed union or the formation of an intraosseous inclusion cyst may occur. [16]

The advantages of simple trephination include less pain for the patient, shorter length of stay, and less costly intervention. [15]

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