What is the role of trephination in the treatment of nailbed injuries?

Updated: Sep 27, 2017
  • Author: Darrell Sutijono, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Various methods of trephination exist (shown in the image below). The easiest and safest is to use an electric cautery, which melts a hole through the nail. Once the cautery encounters the underlying hematoma, the tip cools, preventing further injury to the nailbed. If the hole is of adequate size, blood will drain and relieve some pain and the pressure sensation for the patient.

Trephination of a subungual hematoma. Trephination of a subungual hematoma.

A paper clip may also be used after it is heated until red hot. [25]

An 18-gauge needle may be used by twirling the needle back and forth with slight downward pressure until dark blood return is noted. Use of an 18-gauge needle is less optimal because of the risk of injury to the nailbed once the nail has been penetrated. Alternatively, the needle may be directed at an oblique angle (45-60°) without applying pressure. [26]

Another technique is use of a sterile 29-gauge extra-fine insulin syringe needle. [27] Instead of penetrating the nail, the needle is inserted at the hyponychium parallel to the nail, aimed at the most distal portion of the hematoma. Care is taken to keep the needle closer to the nail versus the nail bed. Once the hematoma is penetrated, the needle may be withdrawn and light pressure placed on the nail will help with evacuation of the hematoma. This technique may obviate the need for digital block anesthesia, and also may be favorable in evacuating hematomas of the smaller toe nailbeds, where trephination is more difficult.

The use of a 2- or 3-mm biopsy punch has also been described. [28, 29] The biopsy punch is gently twirled back and forth with minimal pressure over the hematoma.

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