Subungual Hematoma

imagesTrephination: To create a fistula through the nail to the hematoma

   imagesDecompression, drainage, and pain relief of small subungual hematomas

imagesNail removal and nail bed laceration repair

   imagesLarge hematomas and nail bed lacerations

   imagesPartial nail avulsion or subluxation with nail instability or nail fold disruption

CONTRAINDICATIONS


imagesSignificant crush injuries or missing/destroyed nail matrix warrant specialty consultation

RISKS/CONSENT ISSUES


imagesGerminal matrix injuries and open tuft fractures should be documented and referred to a specialist to ensure optimal outcome

LANDMARKS


imagesHematomas typically collect on the sterile matrix under the nail

imagesGerminal matrix

   imagesRegion where new nail is formed

   imagesAvoid injury during the procedure

imagesGeneral Basic Steps

   imagesX-ray digit if fracture possible

   imagesPrepare patient

   imagesConsider anesthesia

   imagesPerform procedure (FIGURE 73.1)

imagesTrephination

   imagesGoal is to form a hole through the nail of sufficient size to drain the hematoma

   imagesPersonal protection (including an eye shield) as blood may spurt out when released

   imagesNeedle or scalpel method: Apply gentle pressure with the tip of the instrument perpendicular to the surface of the nail, twisting until blood is released

   imagesHeated paper clip method: Creates a wider hole but may tattoo the nail bed

   imagesDisposable electrocautery device method: Quick and effective (FIGURE 73.2)

   imagesDischarge instructions are to soak the finger in warm water twice a day for 7 days to allow the blood to continue to drain

imagesNail Bed Laceration Repair

   imagesSupplies: Iris scissors, hemostats, and suture set with fine absorbable sutures (5-0 to 7-0 chromic or Vicryl)

   imagesPerform digital block under sterile conditions

   imagesApply tourniquet for hemostasis

   imagesRemove the nail from the nail bed matrix

      imagesInsert closed Iris scissors horizontally under the nail

      imagesGently spread scissors and advance in repeated movements, gradually progressing to the nail root and separating the entire nail from the nail bed

      imagesOnce the nail is free from the nail bed and eponychium, grasp with hemostat and gently pull longitudinally to free the nail

images

FIGURE 73.1 Anatomy of the finger and nail bed. (From Eberlein R. Hand and finger injuries. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1048, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Subungual Hematoma

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