Subungual Hematoma
Wednesday, July 22, 2009
Paul Auerbach, M.D.
The following is a message that I received from a reader:"Professor Auerbach - I am an avid reader of your blog 'Medicine for the Outdoors.' Your two posts about foot blisters are really interesting. In my hiking experience there is another foot related issue, that is the subungual hematoma in the toenail. I think it could be an interesting subject in one of your blog posts. Thank you very much for the attention."
Well, it just so happens that I have been a sufferer myself, so I'm happy to write a bit about this. Subungual hematoma refers to blood under a toenail or fingernail. In the fingers, this usually occurs from a blow or pinch, such as catching a finger in a door or striking it with a hammer. In the foot, it is commonly caused by repetitive blows in a confined space, such as hiking in a boot with a toe-box that is too small and/or too stiff. The photo above is my foot after a 10 mile hike over rocky terrain in hiking shoes that didn't fit quite right. They were broken in, but they weren't sufficiently flexible for that type of hike. A couple of hours in, I knew I was in trouble because of the pain, but there was no turning back. No surprise, when I took off my sock, I saw the blue color and knew that eventually that particular toenail was a goner.
What can be done about this condition? When it first happens, applying an ice pack might relieve the pain. Certainly, you should trade out the poorly fitted shoes for ones that provide greater room and comfort. If possible, curtail hiking activities for a day or two, and let the situation settle, or the blood collection might increase.
When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure may be quite severe. If the pain is intolerable, it is necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by heating a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use a needle-nose pliers, if available) and quickly pressing it through the nail. Another technique is to drill a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer an antibiotic (such as dicloxacillin, erythromycin or cephalexin) for 3 days.
In the case of my toe (above), the pain subsided with a day's rest from hiking, so there was no benefit to be obtained by draining the blood. A new nail grew in underneath the one shown in the picture, with the entire process taking a full nine months from injury to nail replacement.
Preview the Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 24-29, 2009.
Tags: subungual hematoma, fingernail, toenail, wilderness medicine, outdoor medicine, healthline
Labels: bloody fingernail, bloody toenail, subungual hematoma
4 Comments:
At Thu Jul 23, 08:36:00 AM 2009,
Jeremy Joslin, MD said…
Most people don't realize this, but the part of the nail you drill through is not alive and has no pain receptors. You can easily get through the nail without feeling anything except some pressure (and if you twirl and drill, you don't even feel pressure).
The important step is once you get through the nail, there's a few millimeter space between the nail and nail bed where the blood has collected. You should top exerting any pressure once you're in this space because the nail bed underneath has some very wild pain receptors. You'll know you hit "pay dirt" once the blood comes pouring or squirting out the hole you've made. That part has actually been described to me as feeling good (it's all the pressure being relived).
Having just returned from working the Gobi March, I had the pleasure of performing this procedure about 30 times during the week-long event.
At Sun Jul 26, 04:27:00 PM 2009,
Anonymous said…
Dr Auerbach - thanks for the explanation! Can you expand on this a bit more to include when a bruise becomes something that should be seen by an MD?
When a limb has suffered a bruise, does gravity make the blood in the tissues go to the lowest point (arm or foot) or does this indicate continued bleeding?
Thanks!
At Tue Jul 28, 08:38:00 AM 2009,
Cockroach Catcher said…
Thank you for being part of the Tour de Grande Rounds.
The Cockroach Catcher
At Thu Jul 30, 09:29:00 PM 2009,
Paul Auerbach, M.D. said…
With regard to the bruised toe, there is really no reason to see a physician unless you suspect an underlying broken bone and wish to obtain a diagnosis, or the blood under the nail is causing so much pain that you need assistance in draining it. Bruises elsewhere on the body, and that occur for different reasons, are an entirely different matter. For instance, spontaneous bruising in multiple locations might represent a serious bleeding disorder. When a limb has suffered internal bleeding, gravity will sometimes cause the bruise to appear at a point lower than the level of the actual injury. This does not usually indicate continued bleeding, which is more likely to be manifested as expanding margins (extension) of the bruise and perhaps the onset of or an increase in swelling.
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