The management of subungual hematomas has simplified in recent years. It was once taught that if the size of the hematoma was greater than 50% of the nail surface, then there was a likelihood that a nail bed laceration was present. It was recommended that the nail be removed and the nailbed laceration repaired. That is no longer the case. No matter what the size of the hematoma, if the nail itself is intact, in proper position and not loose, then simple trephination alone is carried out. Any nailbed laceration will heal well without the need of sutures.

On the other hand, if the nail is loose, it should be taken off. Any bed laceration is repaired with two or three absorbable sutures to provide stability of the bed that is lost without an intact nail in place.

With subungual hematomas, there can be an accompanying distal phalanx or tuft fracture. These might be considered open fractures but they do not require prophylactic antibiotics. After trephination or bed repair, a simple aluminum hockey stick splint can be applied over a non-bulky, non-adherent dressing.

If the nail is removed and the bed repaired, is has been routine to temporarily replace the nail to prevent the cuticle from adhering to the nailbed. That practice has been called into question and can cause an increase in complications.

Avulsion-Tissue Loss Injuries