Evacuation of Subungual Hematoma With an 18-Gauge Syringe Needle

An injury to a finger or toe can result in a collection of blood under the nail plate that, if unrelieved, can cause extreme discomfort due to pressure. In this case, a 22-year-old man developed a subungual hematoma of the right index finger due to a crush injury. Controlled nail trephination was performed using an 18-gauge needle that penetrated the nail plate without breaching the nail bed. The subungual hematoma was successfully drained, and there was a substantial relief in pain immediately. This technique appears to be a quick and convenient method of evacuating subungual hematomas with minimal discomfort and minimal risk.

  Crush injury to the distal part of a finger or toe commonly produces a painful subungual hematoma. The accumulation of blood under the nail results in a bluish discoloration and intense pain caused by pressure,^1,2 and prompt decompression of the hematoma results in immediate relief of the symptoms. The most common method of treatment is nail trephination. For decades, physicians have used heated paper clips, heated needles, dental burrs, fine-pointed scalpel blades, drills, cautery devices, or carbon dioxide lasers for trephining.^1-5 The authors evacuate subungual hematomas successfully and easily with an 18-gauge needle in the emergency department.

  A 22-year-old male experienced a crush injury of his right index finger while playing basketball. His immediate pain persisted and evolved into a severe throbbing pain coincident with the development of a blue/black hue of the entire visible nail within 5 minutes. The patient presented to the authors’ emergency department (Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan) 2 hours later; physical examination revealed no breaks in the skin as well as a severe point of tenderness on the dorsal nail. The diagnosis of subungual hematoma was made. The nail was cleaned using alcohol and allowed to dry. The pooled blood under the nail was visualized using a bright light and the central part of the hematoma selected for evacuation. No local anesthesia was required.   The point of an 18-gauge needle was placed over the site of the hematoma and twisted lightly between the index finger and the thumb (Figure 1A). With this method, the needle acted as a drill, slowly penetrating the nail in an oblique angle, between 45 and 60 degrees, with no pressure needing to be applied to the needle by the thumb and index finger. After 1 minute, approximately 0.2 mL of blood appeared at the tip of the needle and the patient had immediate pain relief. Due to the shape of the needle, it had to be advanced a bit further after blood was obtained to achieve continued evacuation of the hematoma. The nail was then cleared of debris and blood using alcohol and sterile gauze. Total evacuation of the hematoma was achieved (Figure 1B) by applying light pressure to the nail. The patient did not complain of pain and had only slight tenderness. Because of the prompt resolution of the pain and absence of any deformity, no x-ray was ordered.

  Subungual hematomas occur frequently after a crush injury to a digit, and can cause extreme discomfort due to the buildup of pressure under the nail plate. Drainage of the hematoma provides immediate and lasting relief, whereas analgesics only provide temporary relief. The pain incurred by the current methods of drainage limit their applicability. These methods include using a heated paper clip, electrocautery, or a presterilized needle to bore a hole in the nail plate, as well as nail plate removal.^1-5   The treatment of a simple subungual hematoma requires subungual decompression, which is usually achieved by creating small holes in the nail plate.^1-5 Draining the blood from the nail plate with an 18-gauge needle is significantly less painful than 1 injection of digital nerve block. Because the needle causes little trauma and there are no nerves in the nail plate, the patient feels minimal pain and tolerates the procedure quite well; therefore, there is no need for anesthesia. In its early stage, the subungual hematoma is in a small space with high pressure; therefore, the hematoma appears obscure at first. In the late stage of the process, the hematoma becomes more widespread because of the progression of the blood, peripherally between nail plate and nail bed, due to the pressure. Thus, the late lesions appear larger and can be observed more easily. However, in late cases, this progression may cause secondary dystrophy if it reaches to the matrix.⁶ Therefore, early treatment is important.

  This procedure is a fast, simple, well-tolerated technique that is particularly successful for the treatment of subungual hematoma. The only instrument required is an 18-gauge needle and, because the needle is sterile, the risk of infection is minimal. It is cosmetically superior to nail trephination because the nail plate is left intact. For these reasons, the authors suggest this technique as an alternative to the traditional nail trephining methods.

  The authors would like to thank the Civilian Administration Division of the Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.

The authors are from the Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.

Address correspondence to:
Yuan-Sheng Tzeng, MD
Division of Plastic and Reconstructive Surgery Department of Surgery
Tri-Service General Hospital National Defense Medical Center
No. 325, Section 2, Cheng-Gung Road Taipei, 11490, Taiwan
aarondakimo@yahoo.com.tw

Disclosure: The authors disclose no financial or other conflicts of interest.