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Evidence
Total Notes: 10
Evidence

1 Subungual hematoma

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.



References:
  1. The deformed finger nail, a frequent result of failure to repair nail bed injuries.
    Ashbell TS, Kleinert HE, Putcha SM, Kutz JE
    J Trauma. 1967;7(2):177.
  2. Comparison of nail bed repair versus nail trephination for subungual hematomas in children.
    Roser SE, Gellman H
    J Hand Surg Am. 1999;24(6):1166.
  3. Fingertip and nailbed injuries.
    Stevenson TR
    Orthop Clin North Am. 1992;23(1):149.
  4. Fingertip and nail bed injuries.
    Hart RG, Kleinert HE
    Emerg Med Clin North Am. 1993;11(3):755.

2 Possible phalanx fracture

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.



References:
  1. Subungual hematoma: association with occult laceration requiring repair.
    Simon RR, Wolgin M
    Am J Emerg Med. 1987;5(4):302.

3 Anxiolysis

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).



References:
  1. Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey.
    Annequin D, Carbajal R, Chauvin P, Gall O, Tourniaire B, Murat I.
    Pediatrics. 2000 Apr;105(4):E47.
  2. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair.
    Luhmann JD, Kennedy RM, Porter FL, Miller JP, Jaffe DM
    Ann Emerg Med. 2001;37(1):20.
  3. Efficient intravenous access without distress: a double-blind randomized study of midazolam and nitrous oxide in children and adolescents.
    Ekbom K, Kalman S, Jakobsson J, Marcus C
    Arch Pediatr Adolesc Med. 2011;165(9):785.
  4. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases.
    Zier JL, Liu M
    Pediatr Emerg Care. 2011 Dec;27(12):1107-12.
  5. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation.
    Babl FE, Oakley E, Seaman C, Barnett P, Sharwood LN
    Pediatrics. 2008 Mar;121(3):e528-32.
  6. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;367(9512):766.

4 Cleaning nail

If electrocautery is to be used, one should not clean the nail with isopropyl alcohol as it can ignite.



References:

5 Insulin syringe technique

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.



References:
  1. Extra-fine insulin syringe needle: an excellent instrument for the evacuation of subungual hematoma.
    Kaya TI, Tursen U, Baz K, Ikizoglu G.
    Dermatol Surg. 2003 Nov;29(11):1141-3.

6 Boring needle technique

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.



References:
  1. Practice tips. Trephining subungual hematomas.
    Bonisteel PS
    Can Fam Physician. 2008;54(5):693.
  2. Management of finger injuries. In: Textbook of Pediatric Emergency Procedures, 2nd
    Antevy PM, Saladino RA.
    Lippincott Williams & Wilkins, Philadelphia 2008.p.939.

7 Electrocautery or carbon laser

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.



References:
  1. An improved approach to evacuation of subungual hematoma.
    Palamarchuk HJ, Kerzner M
    J Am Podiatr Med Assoc. 1989;79(11):566.
  2. Surgical pearl: prompt treatment of subungual hematoma by decompression.
    Helms A, Brodell RT
    J Am Acad Dermatol. 2000;42(3):508.

8 Mesoscission

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.



References:
  1. Controlled nail trephination for subungual hematoma.
    Salter SA, Ciocon DH, Gowrishankar TR, Kimball AB
    Am J Emerg Med. 2006;24(7):875.

9 Distal phalanx fractures

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.



References:
  1. Subungual hematoma: association with occult laceration requiring repair.
    Simon RR, Wolgin M
    Am J Emerg Med. 1987;5(4):302.
  2. Treatment of subungual hematomas with nail trephination: a prospective study.
    Seaberg DC, Angelos WJ, Paris PM
    Am J Emerg Med. 1991;9(3):209.

10 Notes

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.



References:
  1. Management of finger injuries. In: Textbook of Pediatric Emergency Procedures, 2nd
    Antevy PM, Saladino RA
    Lipp.939.
  2. A study of nail bed injuries: causes, treatment, and prognosis.
    Zook EG, Guy RJ, Russell RC
    J Hand Surg Am. 1984;9(2):247.
  3. Management of injuries of the distal phalanx.
    Zacher JB
    Surg Clin North Am. 1984;64(4):747.
  4. Subungual hematoma: association with occult laceration requiring repair.
    Simon RR, Wolgin M
    Am J Emerg Med. 1987;5(4):302.
  5. Treatment of subungual hematomas with nail trephination: a prospective study.
    Seaberg DC, Angelos WJ, Paris PM
    Am J Emerg Med. 1991;9(3):209.
  6. Comparison of nail bed repair versus nail trephination for subungual hematomas in children.
    Roser SE, Gellman H
    J Hand Surg Am. 1999;24(6):1166.
  7. Treatment of uncomplicated subungual haematoma.
    Batrick N, Hashemi K, Freij R
    Emerg Med J. 2003;20(1):65.