In the case of the isolated subungual hematoma, xrays cold normal, and nail plate often remains well attached to the nail bed.  The patient's only complaint and finding is a painful fluid collection under the proximal-central nail plate. If the patient has presented early, then hopefully there has not been time for infection purulence to develop.

Hence, it merely becomes necessary to block, e.g., anesthetize, the digit following alcohol swab prep; then, perform sterile (clean) prep as this is a clinic procedure, and being a toenail, flora count is best reduced with your prep of choice (i.e., betadine or chlorhexadine). 

Now, carefully puncture the nail plate with a large gauge needle in a slow twisting fashion until sero-sanguinous fluid is able to be expressed.  If exudate is purulent or more than seems possible for a subungual recess, then assess for a draining sinus tract from one of the nail folds.  In such a case, a mini-I&D w/ partial or total nail avulsion may be required.

When puncturing and draining the toe nail plate, do take care to only advance until only the very tip of the needle has penetrated the nail plate, carefully watching the bevel at the end of the needle. 

 

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Use counterpressure with the lateral digits of your hand against the top of the foot while holding the needle.  The other hand of the surgeon is holding the hallux digit steady.  I always like to inform the patient that I am going to lean on your foot a little bit here because that part is not numb and they are not asleep.  It allays their concern, calms their nerves, and removes worry over being touched where the problem is not.

Apply pressure dressing for 24 hrs.

Twice daily soaks in your recipe of choice and your post-procedure regime should suffice.

Educate on potential signs and symptoms of infection, and follow-up in 1 week.

WG

 

  • Comments (2)
  • Agreed, this particular procedure has limited application, and I have actually found few occasions where the indications were met to perform it on an isolated basis.  Usually, the trauma to the ungual region was a bit more extensive, and total nail avulsion w/ washout was required.  This was true especially in the rough on their feet military population, in and out of boots, on and off duty, in and out of the field, while in training or in recreational activities.

  • There is a lot of literature supporting what you just described above. It is certainly a mainstay in podiatry. I have found it of limited use though except if the injury is very fresh. If more than half of the nail bed is affected by the hematoma, I just find it simpler to do a total nail avulsion. This has been what I have done over 90 percent of the time.