Subungual Hematoma

Philip R. Cohen, MD; Keith E. Schulze, MD; Bruce R. Nelson, MD

Disclosures

Dermatology Nursing. 2007;19(1):83-84. 

Clinical Presentation

History

A 47-year-old Caucasian male, who was running a 26.2 mile marathon, experienced the acute onset of severe pain localized to the distal right great toe that began at mile 18. Within 2 days, the toe became less tender; however, the initial red discoloration beneath the nail plate had darkened.

Description of Skin Lesion

In comparison to his normal left great toenail, there was purple-black discoloration of the nail plate and proximal nail fold of his right great toe (see Figure 1). The top view (see Figure 2A) and side view (Figure 2B) of the digit show discoloration of nail plate overlying not only the lunula, but also the distal nail bed.

Figure 1.

The nail plate and proximal nail fold of the right great toe subungual hematoma appear as a purple-black discoloration in contrast to the normal-appearing left great toenail.

Figure 2.

Closer views of the subungual hematoma from the top (A) and side (B) of the right great toe demonstrate the nail plate discoloration that overlies the lunula and extends to the borders of the distal nail bed.

Figure 2.

Closer views of the subungual hematoma from the top (A) and side (B) of the right great toe demonstrate the nail plate discoloration that overlies the lunula and extends to the borders of the distal nail bed.

Etiology

Athletes may develop sports-related subungual hematomas. Repeated trauma to the nail bed occurs each time the toe contacts the inside of the sneaker. Eventually there is bleeding beneath the nail plate. Since the nail stays in place, blood collects beneath it and a hematoma forms. The increased pressure beneath the nail plate results in excruciating pain.

Location

The affected digit often correlates with the sport the 4th and 5th toes in runners and joggers, the 2nd and 3rd toes in soccer and squash players, and the great toe in tennis players.

Hallmark of the Disease

An acute or recent subungual hematoma presents as a painful red discoloration of the nail plate; often there is a known history of trauma to the affected digit. In contrast, a chronic or older lesion appears as a dark blue, purple, or black nail plate discoloration and is usually not tender.

The differential diagnosis of subungual hematoma includes benign and malignant tumors, longitudinal pigmented band (melanonychia striata), onychomycosis, and subungual exostosis. An x-ray of the distal digit should be performed if a fracture of the underlying phalynx is suspected. If the lesion is chronic and the patient is unable to recall a history of trauma to the nail, it may be necessary to rule out a pigmented lesion, such as a melanoma, with microscopic examination of both the nail plate and the biopsy specimen from the underlying nail matrix and/or nail bed.

Treatment

Evacuation of the hematoma not only provides immediate pain relief but also aids in minimizing additional damage to the nail bed and nail matrix. When the lesion is less than 48 hours old, piercing of the nail plate overlying the hematoma (referred to as trephination) can be performed using any of the following modalities: a hot paper clip cautery (held with a hemostat), a hot No. 18 needle, a hand engine with a dental bur, a scalpel blade used as a drill, or a hand-held cautery unit. The heated trephine is directed perpendicular to the nail plate overlying the hematoma; slow and gentle pressure is applied cautiously until blood exits from the nail plate surface. If the lesion is older than 48 hours, the blood may no longer be free flowing and avulsion of the nail plate may be necessary to evacuate the hematoma.

Normal Course

Relief of pain and continued growth of the intact nail plate can follow the successful trephination of an acute subungual hematoma. However, onycholysis and shedding of nail plate may occur following decompression treatment, especially when the hematoma involves more than 25% of the nail plate. Since toe nails grow at an average rate of 1 mm per month, complete growth of a new toe nail ranging in length from 1.0 to 1.5 cm would require 12 to 18 months. Transient or permanent nail deformity and, infrequently, infection are also possible complications following subungual hematoma evacuation.

Patient Education

Patients should be encouraged to wear appropriate-fitting footwear to prevent traumatic injury between their toenails and the sneaker.

Nursing Measures

After successful trephination and evacuation of an acute subungual hematoma, a pressure dressing should be applied to prevent reaccumulation of blood and to promote adherence of the nail plate to the nail bed. If the hematoma is chronic and the nail plate was avulsed, antibiotic ointment and a Telfa dressing should be applied prior to bandaging the distal digit firmly.

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