Treatment of uncomplicated subungual haematoma
Date First Published:
March 1, 2000
Last Updated:
January 23, 2003
Report by:
Nicola Batrick, Specialist Registrar (Mayday University Hospital)
Search checked by:
Kambiz Hashemi and Ramzi Freij, Mayday University Hospital
Three-Part Question:
In [a patient presenting with a sizeable uncomplicated subungual haematoma] is [removing the nail and repairing the nail bed laceration better than simple trephining] at [providing the best cosmetic and functional result]?
Clinical Scenario:
A patient attends the emergency department having sustained a crush injury to the tip of their right index finger. This has resulted in a painful subungual haematoma but no other significant fingertip injury.
Search Strategy:
Medline 1966-10/02 using the OVID interface.
Search Details:
[subungual haematoma.mp OR nail bed laceration.mp OR nail bed injuries.mp OR exp NAILS/su] LIMIT to human AND English.
Outcome:
Altogether 312 papers were identified of which 308 were considered to be irrelevant or of insufficient quality for inclusion. The other 4 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Subungual hematoma:Association with laceration requiring repair. Simon RR, Wolgin M. 1987, USA | 47 consecutive patients presenting to an emergency department with subungual haematoma > 25% nail bed. +/- fracture of distal phalanx Digital block, nail removed and lacerations of nail bed greater than 2-3 mm repaired using vicryl and nail replaced |
Prospective observational study | Association of SUH size and repairable laceration | 16/27 patients with haematoma >50% had nail bed laceration requiring repair | Often quoted paper but no follow up of patients and no control group |
| Treatment of subungual hematomas with nail trephination: A prospective study. Seaberg DC, Angelos WJ, Paris PM. 1991, USA | 48 patients presenting to an emergency department with subungual haematoma Nail and nail margin intact. +/- distal phalanx fracture Electrocautery nail trephination Follow up at least 6/12 |
Prospective observational study | Pain relief, infection and cosmetic appearance | 94% follow up. All reported a reduction in pain. No infective complications or major nail deformaties regardless of SUH size or fracture | Major nail deformaties not clearly defined No control group |
| Subungual haematomas: is simple trephining enough? Meeks S, White M. 1997, UK | 123 patients presenting to emergency departments treated by simple trephining 94 followed up for 5-13 months |
Retrospective | Functional and cosmetic appearances | Excellent ie no residual abnormality or very good in 85% of those followed up.<br><br>2% poor outcome caused by nail splitting. Major nail abnormality defined by Zook's criteria occured in 11% | Retrospective Coding inadequate No control group Loss of patients to FU |
| Infection | Infection in 5 patients. No correlation between adverse outcome and haematoma size, presence of fracture or infection | ||||
| Comparison of nail bed repair versus nail trephination for subungual hematomas in children. Roser SE, Gellman H. 1999, USA | 53 finger injuries in children with intact nail and nail margin, +/- tuft fracture. Formal nail bed repair v simple trephining/ conservative. FU at least 4/12 |
Sequential study | Cosmetic deformity of nail and functional deficit | Operative and non-operative- nil at long term FU | No randomisation |
| Infective complications | No infective complications in either group | ||||
| Costs | Costs significantly higher in operative group |
Author Commentary:
It has been suggested that for subungual haematomas greater than 50% of the nail bed, the nail should be removed and the associated nail bed laceration repaired to ensure optimal cosmetic and functional results. However, there are insufficient clinical studies comparing treatment modalities to support this. It appears from the studies quoted that simple trephining of the nail in an uncomplicated SUH with no other significant finger tip injury gives good cosmetic and functional results.
Bottom Line:
In both adults and children with a SUH with no other significant finger tip injury, treatment by trephining gives a good cosmetic and functional result.
References:
- Simon RR, Wolgin M.. Subungual hematoma:Association with laceration requiring repair.
- Seaberg DC, Angelos WJ, Paris PM.. Treatment of subungual hematomas with nail trephination: A prospective study.
- Meeks S, White M.. Subungual haematomas: is simple trephining enough?
- Roser SE, Gellman H.. Comparison of nail bed repair versus nail trephination for subungual hematomas in children.