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Trauma to the nail (i.e. crushed by closing door, stubbed toe, blunt strike, etc.) may cause bleeding within the nail matrix causing a dark hematoma to form under the nail. This hematoma may be very painful and cause scaring to the nail matrix if not evacuated. This scaring has the potential to cause a disruption in the growth of the nail causing permeant deformity of the nail.
Trephination (creating a hole in the nail) allows for relief of the pressure and pain cause by the hematoma and improves healing. This should be accomplished as early as possible as most subungual hematomas clot within the first 48 hours from injury.
Trauma significant enough to cause a subungual hematoma is often adequate to cause distal phalanx fractures. Although, small hematomas may be followed supportively, most large hematomas (especially > 1/2 surface area of nail) should have x-rays to evaluate for fracture.
A nail trephination can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the safety of the procedure and the provider’s ability to perform the procedure. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.
Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrous oxide.
Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).
A nail trephination can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the safety of the procedure and the provider’s ability to perform the procedure. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.
Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrous oxide.
Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).
A nail trephination can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the safety of the procedure and the provider’s ability to perform the procedure. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.
Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrous oxide.
Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).
If electrocautery is to be used, one should not clean the nail with isopropyl alcohol as it can ignite.
The insertion of an insulin syringe distal to the nail and evacuating the hematoma has been shown to work well. It should be noted that this technique should only be used for distal hematomas on the nail plate.
Multiple studies have shown that the use of an 18 - 20 gauge needle twirled in the fingers to bore into the subungual hematoma to be effective. With the wide use of electrocaudery this needle technique may be less optimal as there is the possibility of pain from pressure applied to the nail as it is pushed through the nail as well as the potential for damage to the nail be from the needle itself.
Electrocautery is a safe and effective method to evacuate a subungal hematoma. Key to the technique is to make enough (2+) holes that are large enough (3-4 mm) to ensure drainage as the holes have a tendency to clot off.
A messoscission device uses a small motor to bore multiple holes in the nail over a subungual hematoma. Attached to the device are pads that measure electrical resistance which tell the device when it has gone through the nail and reached the hematoma. The device stops the boring prior to disruption of the nail bed.
Phalanx fractures are commonly associated with subungual hematomas (up to 32 percent). The larger the hematoma, the more likely there is a fracture (especially > 50 percent coverage of the nail). These fractures will require splinting once the hematoma is evacuated.
One should assume that a distal phalanx fracture in conjunction with a subungual hematoma is an open fracture. However, if the patient has an intact nail fold, the risk of infection is very low and prophylactic antibiotics can be avoided.
Paper clip
Use of a heated paper clip or other metal rod is not usually recommended for trephination given that different metals may not provide adequate thermal conduction and there is exposure to open flame.
Nail removal
When large subungual hematomas are present there is a chance for a laceration of the nail bed below the nail. Although there is no consensus, several studies have shown that nail removal and repair does not improve outcomes. Therefore, simple trephination is likely adequate for these patients.
A nail trephination can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the safety of the procedure and the provider’s ability to perform the procedure. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.
Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrous oxide.
Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).
A nail trephination can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the safety of the procedure and the provider’s ability to perform the procedure. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.
Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrous oxide.
Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).
