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Straight, No Chaser: Blood Under Your Nail – Subungual Hematomas

By Jeffrey Sterling, MD July 10, 2020

ET glowing finger

So you’ve banged your finger with a hammer or stubbed your toe on a wall. Now the nail looks like ET’s? What are you supposed to do about that? What is that? This Straight, No Chaser introduces you to subungual hematomas, which translates blood collection (hematoma) under the nail (subungual).

subungal hematoma

We bang our fingers and toes. We’re supposed to. We’re designed that way. The tips of our fingers and toes are the leading edges of the body, and they help us explore the world around us. Injuries to these outermost reaches of the body (no pun intended) should be taken seriously. Our ability to touch and feel is a large component of our ability to function. The long term presence of blood in certain undesirable areas can have corrosive effects. Furthermore, if we’re not healthy the parts of our body that are most distant from our heart are most likely to experience the effects of poor circulation. (It’s harder work for the heart to pump blood to the fingers and toes than to our core.) Healing the damaged areas, then, may be much slower than in normal, healthy individuals. Herein lies the importance in addressing various injuries to these areas.
So what should you do about it? If the affected area is less than a quarter (25%) of the nailbed, and if the injury is painless, no treatment is required. The body is able to resorb this amount of blood without significant damage occurring. Any injury larger than this should definitely be evaluated.
If your physician elects to drain the blood, that may occur in various ways, including the following:

subungal cautery

  • Electric cautery is quick, safe and easy. In a manner of a second or two, the tool is used to melt a small hole through the nail. The blood will drain through the hole and your sense of pain and pressure will resolve. Sounds scary? Well, the medical tools used are designed so the cautery tip cools once it enters the area of blood (hematoma). This really shouldn’t be a painful procedure.

subungal needle

  • Alternative methods include use of sterile medical needles or biopsy punch tools. These objects are generally used to screw a hole into the nail until it reaches the hematoma. This sometimes results in a small gush of blood as the pressure is released. Even though it’s less intimidating that cautery, in the hands of someone relatively less skilled the needle is more likely to cause some pain.

 

subungal postcautery

Treatment of simple subungual hematomas are, well, simple – in the large majority of cases. Once the level of the hematoma is reached, you see rapid clearing of the nail. In less common instances of major trauma to the nail, there may be associated underlying fractures and more extensive damage to the tissue under the nail. Suffice it to say, you’ll know if this is the case.

In short, the next time you bang your nail, first see if it’s 25% of the total area, then make a decision about getting it evaluated. I suspect that’s why ET wanted to go home. His finger looks inflamed to me.

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