The protocol for Subungual Hematoma:Subungual Hematoma
Let’s break it down!
The term “Subungual Hematoma” sounds so much scarier than what it actually is. If you break down the term, it’s just “Sub” (underneath) – “Ungual” (nail) – “Hematoma” (collection of blood)
Subungual Hematomas can be caused by any number of acute events: finger slammed in the door, thumb hit with a hammer, dumbbell dropped on a toe, etc. But oftentimes, it can also be the result of repetitive pressure on the nail bed. For example, runners who have tight or misfitting shoes will sustain repetitive trauma to their toes, causing subungual hematomas. That’s why sometimes you may hear these injuries described as “Runner’s Toe“.
The video below is a nice introduction on the topic:
Need I say more? Here are some pictures to reinforce your diagnostic excellence:
And yes, it will be tender to palpation! 👉
The primary treatment for subungual hematomas is a procedure called Nail Trephination, which involves draining the blood out from underneath the nail plate. This will help relieve the patient’s pain and potentially decrease the recovery time. When possible, it should be done within 48 hours of the injury (otherwise, the blood may clot and the procedure will be ineffective). This video shows the classic way to perform a nail trephination with an 18 gauge needle:
If you have a Cautery Pen, this also works well for nail trephination procedures:
2. Treat per Pain Management protocol
Nail trephination by itself is usually good enough to relieve most of the pain, but that doesn’t mean that the patient will be pain-free The toe is still injured and a new nail will likely form underneath the injured one and push it out, which isn’t always comfortable. Conservative pain management with a short term supply of Tylenol or NSAIDs would be appropriate for most patients.
3. Tape/Splint if fracture suspected
How do we know when to suspect a fracture? We mostly have to rely on good clinical judgment. Obviously a deformity in the affected area is a great indicator, but the inability to walk on a toe without significant pain would be a sign of fracture as well. Some even suggest that any hematoma that covers at least half of the nail bed is commonly associated with fractures. In addition, 50% of nail bed injuries (as indicated by a torn or shattered nail plate) are associated with a distal phalanx fracture. We’re always going to tape/splint if we suspect a fracture, but if it’s tactically feasible to get the soldier an X-ray, we should recommend that so that we can ensure that it heals correctly.
For splinting fingers, you can use one of the methods described in the video:
For splinting toes, the buddy method is typically the best way to go:
Evacuation isn’t typically needed unless you suspect a fracture. Minor subungual hematomas will often themselves over time, regardless of treatment. If the entire nail is compromised, it’ll take up to 8 weeks for a fingernail to grow back and 3-6 months for a toenail.
Good luck out there!
- EM:RAP Corependium (Hand, Foot and Amputation Injuries)
- UpToDate: Subungual Hematoma
- Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.