• Subungual hematoma with pain.
• Some experts suggest that nail removal and repair should be prompted
by the percentage of nailbed involved (eg, greater than 25–50%),
but this is not supported in the literature.
• Procedure is limited to simple hematomas, not
complex crush injuries with associated fractures or nailbed injuries.
• Do not trephinate artificial acrylic nails using cautery (flammable).
• Do not prepare the nail with alcohol (also flammable).
• 10% povidone-iodine (or equivalent).
• Sterile gloves and gauze.
• Single-use, disposable electrocautery device (sterile) is preferred.
• A needle or metal paperclip heated in a flame is an alternative
to electrocautery. A metal paperclip is preferred because it is
blunt and will do less damage if inserted too far.
• Another alternative is to use either an #11 blade or
18- or 20-gauge needle in a twisting motion to drill the nail.
• Infection (very rare).
• Pain (if done correctly, procedure should provide pain relief).
• Nail deformity (rare, and associated with more complex injuries).
• Immobilization is important for young children;
movement during the procedure can lead to injury to the nailbed
• Hide the cautery device from view of the young child until just
before the procedure. Explain the procedure to older children, emphasizing
that holding still will prevent pain.
• Do not mistake the pain of an underlying fractured phalanx for
the pain of a hematoma.
• Obtain a radiograph if indicated by history or examination.
• Consider nail removal or specialist consultation for management
and follow-up when any of the following is present:
• The nail or nailbed is disrupted.
• There is a displaced fracture of the phalanx.
• There is substantial periungual blood (suggesting eponychial
• A hematoma in this space that cannot drain spontaneously causes
pain that is sometimes severe.
• The nail itself is insensate, but the nailbed is very sensitive.
• The key to a pain-free procedure is to puncture the nail without
entering the nailbed.
Sagittal view of the nailbed.
• With the hand properly positioned and immobilized
(if necessary), the cautery device is heated and then applied to
the nail in the center of the hematoma area.
• Little or no pressure is required to penetrate the nail, particularly
in small children with thin nails.
• Immediately upon entering the subungual space, blood will escape
and a sizzling sound will be heard (from the blood hitting the cautery
• Immediately withdraw the blade.
• Slight pressure will express more of the remaining fluid.
• Older hematomas ...
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