20 EMN I October 2010 Evaluation and Treatment of InFocus Subungual Hematoma By James R. Roberts, MD Author Credentials Finan- cial Disclosure: James R. Roberts, MD, is the Chair- man of the Department of Emergency Medicine and the Director of the Divi- sion of Toxicology at Mercy Catholic Medical Center, and a Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, both in Philadelphia. Dr. Roberts has disclosed that he is a member of the Speakers Bureau for Merck Pharmaceuticals. He and all other faculty and staff in a position to 12 control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no fi- nancial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. Learning Objectives: After participat- ing in this activity, the physician should be better able to: 1. Formulate a plan to identify subun- gual hematomas that require simple nail trephination vs. nail removal. 2. Select the correct method of provid- ing nail trephination. 3. Predict the need for prophylactic an- tibiotics after hematoma evacuation. 5 mergency physicians frequently deal with patients who have suf- Efered trauma to the digits. This month’s column begins a series of discus- sions on a rational approach to fingertip problems by reviewing the ubiquitous subungual hematoma (SUH). SUHs are rather common, and cause incapacitating and throbbing pain, prompting the hardiest of souls to seek relief. Even narcotics may fail to relieve the pain produced by an ex- panding subungual hematoma as it compresses the sensitive nailbed so some method to release the pressure is usually required, and is usually imme- 6 7 diately curative. Few randomized con- trolled studies have critically evaluated therapeutic modalities, but clinical practice has identified the salient is- seasoned physicians are not cognizant Treatment of Subungual sues. Treatment recommendations Part 1 in a Series of all the issues. Hematomas with vary, and unsubstantiated clinical After reading this article, emergency Nail Trephination: dogma and waffling recommendations care. The key to a successful outcome physicians should be better able to A Prospective Study are extant. of any fingertip injury is to know when identify which subungual hematomas Seaberg DC, et al SUH is usually not a digit-threaten- to be conservative and when to be ag- require simple nail trephination vs. nail Am J Emerg Med ing injury, and rarely is even a cos- gressive. House staff usually learns removal, select the correct method of 1991;9(3):209 metic concern. But SUH is usually from on-the-job experience. Some providing nail trephination, and predict treated in the ED, and the emergency continue to repeat the mistakes of a the need for prophylactic antibiotics af- This nicely done sentinel study was physician should be an expert in its misinformed mentor because even ter hematoma evacuation. designed to determine if simple nail InFocus October 2010 I EMN 21 trephination alone would adequately fracture did not exclude patients from associated fracture. Although most pa- of the size of the SUH or the presence treat uncomplicated SUH without the protocol. tients with underlying fractures had a of an underlying phalanx fracture. producing or fostering associated The subjects were 3 to 60 years old. greater than 50 percent hematoma, The authors question the need for cosmetic or infectious complica- All underwent radiographic analysis, there was no close correlation be- routine radiographs in all cases, and tions. A subsequent ebidence-based and were treated with electrocautery tween the size of the hematoma and conclude that patients with uncompli- literature review (Emerg Med J trephination and expression of the the presence of a fracture. There were cated SUH will have excellent results 2003;20[1]:65) reached the same con- subungual blood. Antibiotics were not no complications directly related to with simple nail trephination without clusions. prescribed. Postoperative treatment the trephination, and there were no removal of the nail or suturing of the nailbed. This conclusion is contrary to other authors who suggest routine re- moval of a nail to meticulously repair nailbed lacerations. The authors em- phasize that their study examined only cases where the nail and nail margins were completely intact, and their con- clusions may not be applicable to ex- tensive crush injuries or complex nail disruptions. They also believe an elec- trocautery provides the most ideal method for rapid and painless trephina- tion. If a fracture is present, routine pro- tective extension splints also are suggested. There appears to be no role for routine antibiotic coverage, even if 3 4 the phalanx is fractured and the nail has been trephined. COMMENT: It is certainly undesirable 1. There is no SUH from this nail injury, but because 5. Replace the nail under the cuticle and secure it for any patient to end up with a per- the lateral nail margin and nailbed are obviously with lateral sutures. Do not suture through the ger- manently deformed nail, and major lacerated, they should be repaired. The nail has to minal matrix. As an option, drill a hole through the fingertip injuries require a cautious ap- be at least partially removed to accomplish this. replaced nail so any new bleeding will drain. Be proach. While the burly construction Don’t remove the entire nail, just enough to ex- sure to remove the tourniquet before applying any worker may not worry about a funky pose the injured nailbed. Do not avulse the base dressing. In about two to three weeks, the new nail fingertip, a woman showing off her en- of the nail, and preserve the germinal matrix so a gagement ring will. It’s clear, however, new nail will grow normally and cover the lacer- will begin to push out the replaced nail that was that some physicians are truly in a ated bed. used as a splint and dressing. Then you can re- move the sutures, and the replaced nail will fall off, clinical fog when it comes to evaluat- 2. This patient’s fingertip was smashed in a car door, a exposing the repaired nailbed. Cover the nailbed ing and treating SUH. Because of this very common injury that avulsed the nail at the base with a nonadherent dressing. It will take many study and others, most EPs are en- by flexion, and produced a nailbed laceration and weeks (six to eight) for the new nail to completely lightened, and opt for the conservative SUH. This nail should be removed and the nail re- cover the nailbed. simple trephination of even a total paired. SUH when the nail is intact. Hopefully the days are gone when SUH prompts 6. This may seem like a simple SUH, but blood under 3. To remove the nail, use small scissors to tease routine nail removal in search of the the cuticle (arrows) is a tipoff that the base of the the nail away from the nailbed. This will con- nefarious nailbed laceration that re- nail is likely avulsed, allowing blood from the vince you how tenacious the bond is. There is no quires meticulous suturing, repeat vis- nailbed laceration to collect between the skin and cutting involved. Hold the scissors horizontally in its, and a bare nailbed for weeks. base of the avulsed nail, which is now sitting on the plane between the bed and undersurface of Although most EPs approach SUH the nail. Gently spread as the instrument is ad- top of the cuticle. Swelling prohibits this from be- with that philosophy and simply vanced, avoiding further nailbed injury. Note that ing readily appreciated. The nail should be reposi- trephine the nail, it’s easy to get side- a tourniquet is used anytime the distal finger is tioned into its germinal matrix, and it may take tracked with aggressive nail removal repaired. Keep the removed nail to use as a hold and grow. dressing. and fancy nailbed repairs after a cur- sory reading of the hand surgery litera- 7. To accomplish repair of the injury in Photo 6, first 4. To obtain a clean field without annoying drapes, use ture. An SUH is clearly emergency the SUH is totally drained with simple trephina- a glove on the patient’s hand. Meticulously repair medicine turf, and hand surgeons only the nailbed with 6-0 (always use absorbable) su- tion. This avulsed nail may be manipulated back see these minor injuries when there are tures. The goal is to produce an anatomically per- into the germinal matrix with a hemostat (longitu- later complications. Other discussions fect nailbed to avoid ridges or nail deformities as dinal traction, pressure over the proximal nail of fingernail injuries can be found. (J the new nail grows back. base), avoiding total nail removal. Trauma 1967;7[2]:177; Hand Clin 1990;6[1]:37; Orthop Clin North Am James R. Roberts, MD 1992;23[1]:149; Emerg Med Clin North Am 1992;10[4]:801). Over two years, 48 ED patients with included splinting of fractures in cases of soft tissue infection, os- Impressively, and despite much un- SUH entered the study. Patients were extension for one week. Patients were teomyelitis, or permanent significant referenced paranoia about SUH, there excluded if they had disruption of the followed for at least six months after nail deformity. A few patients initially were no signs of permanent nail defor- fingernail itself, if the nail were loose, the injury for evaluation of deformi- had ridges in the nail at the site of mities in any patient in this study. Only the nail border violated, or previous nail ties, dysfunction, or signs of infection. trauma, but these had grown out, and 48 patients were studied, but because deformities existed, leaving only pa- The size of the hematoma was rated the nails appeared normal after three my waiting room is not filled with fin- tients with a closed hematoma, an intact relative to the nail surface area.