Hematoma Subungeal

Written by

 

 

Robert T Brodell MD, FAAD

Dermatologists are expert at identifying quick, simple, reproducible, highly effective technical approaches to skin problems. This is simply a matter of survival in busy practices. In the setting of a crush injury producing a subungual hematoma, it has been known for a long time that a hot paper clip, electrocautery device, or CO2 laser can "melt" a hole in the nail plate relieving the pressure.1 As the blood squirts out the hole, the patients uniformly make an audible sigh a their throbbing pain is relieved and often want to hug their doctor, something that is not permitted in the era of COVID-19. There is a minor problem: patients experience pain when the hot paper clip or heat from the laser or cautery touches the underlying nail bed. A digital block can be performed to eliminate this pain. In addition, the CO2 laser or electrocautery device may not be available. An 18-gauge needle can penetrate the nail. Pushing the needle through the nail, however, magnifies the pain until the nail is breached.2

Of course, avulsion of the nail should be avoided because the nail provides a natural dressing to the nail bed and it is best to avoid exposing an underlying displaced fracture.

These authors describe the use of a 2-mm punch with a spinning motion between the fingers to easily penetrate the nail with minimal pressure because of their super-sharp blade. We all have these small punches in our offices, they are inexpensive, and the treatment works 100% of the time. Brilliant! The only problem: patients need to visit the office soon after the trauma and immediately after their throbbing pain begins. Dissemination of information about this simple treatment may encourage patients to do just that!

References

1. Brodell RT, Helms A. Surgical pearl: prompt treatment of subungual hematoma by decompression. J Am Acad Dermatol. 2000;42(3):508-509. https://www.jaad.org/article/S0190-9622(00)90228-7/fulltext
2. Lin C, Tzeng Y. Evacuation of subungual hematoma with an 18-gauge syringe needle. Wounds. 2014;26(2):E5-E6. https://www.woundsresearch.com/article/how-i-do-it-evacuation-subungual-hematoma-18-gauge-syringe-needle

Sent from my iPhone

Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

Please excuse the shortness of this message, as it has been sent from
a mobile device.