Subungual hematoma

Have you ever injured your toe or finger and immediately suffered from inflammation and a black nail? You might have suffered from Subungual hematoma (SH) in that case. Read on to find out more about this common condition affecting toes and fingers.

What is Subungual Hematoma?

It is a nail condition that can be defined as the accumulation of a cluster of blood or hematoma underneath the nail of a finger or toe. The hematoma develops between the nail plate and the nail itself.

It is sometimes also referred to as:

  • Black toenail
  • Tennis toe
  • Runner’s toe

Subungual Hematoma ICD-9 Code

The ICD-9 codes of this condition are listed below:

  • Contusion of toe – 924.3
  • Contusion of finger – 923.3

Subungual Hematoma Causes

The condition mostly occurs after the tip of toe or finger has sustained a major trauma. The injury can occur in numerous ways, such as:

  • By hitting the finger with hammer or a heavy object
  • By dropping some heavy object on the toe
  • By stubbing the toe on some hard surface
  • By slamming the finger in a house door or a car door
  • By hiking or climbing along a rugged terrain

SH often results from Runner’s toe, a condition that frequently develops in runners. It is caused by the downward pressure of legs or by the horizontal separation of the nail plate from the nail bed. Repetitive trauma causes bleeding as well as pooling of blood beneath the nail plate. The condition is clinically characterized by a reddish-black discoloration of one’s toe nail. The affected nail plate may even become thicker and rather brittle due to injury. However, the distorted nail plate will slowly be replaced naturally by a new nail plate over many months. In some rare cases, the condition of the toe can become very painful and might require surgery.

Runner’s toe is frequently associated with shoes that do not fit properly and provide insufficient space for toes. The bleeding occurs from vascular nail bed which underlies the nail plate. Laceration of nail bed leads to bleeding in the constricted area below the rigid nail plate.

Subungual Hematoma Symptoms and Signs

The problem generally occurs due to a direct wound to the fingernail. Although SH is not considered to be a serious health condition, the pressure exerted by the clusters of blood between nail and nail bed of toes or fingers is known to cause a severe throbbing pain. The pain may also result from other injuries, such as:

  • Fracture of the underlying bone
  • Bruising of the toe or finger
  • A cut in the nail bed

Other signs and symptoms of the problem include:

  • A maroon, red, purple-black or dark discoloration underneath the nail sometime after an injury
  • Swelling and tenderness of the finger or toe

Subungual Hematoma Prevention

Some simple safety measures allow preventing the development of a SH. These include:

  • Being careful so as not to drop heavy objects and tools on your toes or getting your fingers rammed by doors.
  • Wearing steel-toed shoes while engaging in certain high-risk professions, such as construction and engineering.
  • Being watchful of children’s hands so as not to accidentally slam your car door on to their hands.
  • Be fully attentive towards the task that you are involved into. Finger injuries frequently occur when an individual is distracted while using a tool, such as a hammer.
  • Avoid lifting something that is too heavy for you to handle. Always ask for assistance while carrying heavy objects so that you do not drop them on the toes.

Subungual Hematoma Diagnosis

Diagnosis of this condition is carried out by detection of an X-ray image of the wound and by conducting a nail bed evaluation. The X-ray is taken in order to study the possible presence of fracture or breaks of the underlying bone structure. X-rays, however, do not provide physicians with any information about bleeding or the formation of hematoma underneath the nail.

Depending on the degree and type of the injury, as well as the amount of accumulated blood under the nail, a doctor might choose to remove a patient’s nail to check his or her nail bed for cuts or lacerations. However, this procedure is normally not executed if the edges or margins of the nail remain intact.

Subungual Hematoma Treatment

A rather small and painless SH normally needs no treatment. Nevertheless, the pressure generated by the pooled blood under nail can prove to be extremely painful. In order to get rid of the pain, doctors might perform decompression or trephination. This allows drainage of the underlying blood and relieves pressure from the area, thus also alleviating pain.

After using a nerve block to numb the affected toe or finger, the doctors usually use numerous decompression methods in order to drain the region. These involve:

  • Paper-clip method: In this method, a heated paper-clip is positioned over the hematoma’s center for melting a hole in the nail.
  • Cautery: An electrocautery device or a heated wire is used for burning the holes. It is a painless procedure which takes only seconds.
  • Needle aspiration: In this technique, a needle with a large diameter is employed to pierce the nail.

During paper-clip and cautery procedures, the already heated tip is eventually cooled when it comes in contact with hematoma. This prevents any possible injury to nail bed.

Once the decompression procedure is over, the nail is tied or bandaged. Patients are recommended to keep the toe or finger bandaged and elevated. If required, they may also be advised to use cold compresses, especially for the first twelve hours. In some instances, doctors may also recommend using splints for nearly 3 days or as long as the tenderness does not minimize.

The only major complication that can arise from decompression is an infection in residual hematoma.

If a subungual hematoma damages at least half of the total nail surface, the nail bed can suffer significant injury. In such cases, doctors may require removing the nail and adding stitches to the affected nail bed.

Pain medications and antibiotic ointments like Neosporin are also recommended for the treatment of SH.

Subungual Hematoma Home Treatment

The treatment of SH involves compression of the affected area with ice wrapped in a towel. Care should be taken so that the affected toenail or fingernail does not come in direct contact with the ice.

The area can also be treated using a wrap of frozen vegetables such as peas or corn.

If an injury caused the nail to be removed but the nail bed remained uncut, the following measures may be taken to ease the sensitivity of the nail bed, usually for the next 7 to 10 days.

  • Daily soak the affected area with water and antibacterial soap twice for at least 10 to 15 minutes.
  • Soak the region.
  • Following this, apply an antibiotic ointment such as Neosporin.
  • Bind the area with a sterile dry bandage.

Subungual Hematoma Follow-up

Once the affected region has been drained, follow up is usually unnecessary. Routine consumption of antibiotics is not required after the drainage of the area.

Re-examination within 48 to 72 hours is recommended in case the nail gets removed and stitches are administered to the cut nail bed.

Stitches generally dissolve automatically and removal is not necessary. Nylon stitches are however required to be removed by the emergency department or the doctor in about 7-days time.

Close monitoring after immediate medical attention is recommended.

Subungual Hematoma Prognosis

Once the area has been drained, the pressure underneath the nail subsides. This reduces the pain. The hole that is produced in the nail remains and grows at a normal pace.

Subungual Hematoma Complications

Although the prognosis of the disorder is generally good, there is always a risk of nail deformities such as onycholysis and other permanent abnormalities. Nail bed laceration is a possible long-term complication of SH. If the skin below the nail is cut or lacerated, it may not repair properly. This may lead to deformity of nail and nail growth. This deformity, again, may be temporary or permanent.

Subungual Hematoma Pictures

Here are some pictures that show the condition of nails affected by SH.

Picture of Subungual hematoma

Picture 1 – Subungual hematoma

Image of Subungual hematoma

Picture 2 – Subungual hematoma Image

If left untreated, Subungual hematoma can get serious. With proper medical attention, however, one can expect the condition to resolve and the affected region to eventually heal properly.