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Three Part Question

In [a patient presenting with a sizeable uncomplicated subungual haematoma] is [removing the nail and repairing the nail bed laceration better than simple trephining] at [providing the best cosmetic and functional result]?

Clinical Scenario

A patient attends the emergency department having sustained a crush injury to the tip of their right index finger. This has resulted in a painful subungual haematoma but no other significant fingertip injury.

Search Strategy

Medline 1966-10/02 using the OVID interface.
[subungual haematoma.mp OR nail bed laceration.mp OR nail bed injuries.mp OR exp NAILS/su] LIMIT to human AND English.

Search Outcome

Altogether 312 papers were identified of which 308 were considered to be irrelevant or of insufficient quality for inclusion. The other 4 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Simon RR and Wolgin M, 1987, USA	47 consecutive patients presenting to an emergency department with subungual haematoma > 25% nail bed. +/- fracture of distal phalanx Digital block, nail removed and lacerations of nail bed greater than 2-3 mm repaired using vicryl and nail replaced	Prospective observational study	Association of SUH size and repairable laceration	16/27 patients with haematoma >50% had nail bed laceration requiring repair	Often quoted paper but no follow up of patients and no control group
Seaberg DC et al, 1991, USA	48 patients presenting to an emergency department with subungual haematoma Nail and nail margin intact. +/- distal phalanx fracture Electrocautery nail trephination Follow up at least 6/12	Prospective observational study	Pain relief, infection and cosmetic appearance	94% follow up. All reported a reduction in pain. No infective complications or major nail deformaties regardless of SUH size or fracture	Major nail deformaties not clearly defined No control group
Meeks S and White M, 1997, UK	123 patients presenting to emergency departments treated by simple trephining 94 followed up for 5-13 months	Retrospective	Functional and cosmetic appearances	Excellent ie no residual abnormality or very good in 85% of those followed up. 2% poor outcome caused by nail splitting. Major nail abnormality defined by Zook's criteria occured in 11%	Retrospective Coding inadequate No control group Loss of patients to FU
			Infection	Infection in 5 patients. No correlation between adverse outcome and haematoma size, presence of fracture or infection
Roser SE and Gellman H, 1999, USA	53 finger injuries in children with intact nail and nail margin, +/- tuft fracture. Formal nail bed repair v simple trephining/ conservative. FU at least 4/12	Sequential study	Cosmetic deformity of nail and functional deficit	Operative and non-operative- nil at long term FU	No randomisation
			Infective complications	No infective complications in either group
			Costs	Costs significantly higher in operative group

Comment(s)

It has been suggested that for subungual haematomas greater than 50% of the nail bed, the nail should be removed and the associated nail bed laceration repaired to ensure optimal cosmetic and functional results. However, there are insufficient clinical studies comparing treatment modalities to support this. It appears from the studies quoted that simple trephining of the nail in an uncomplicated SUH with no other significant finger tip injury gives good cosmetic and functional results.

Clinical Bottom Line

In both adults and children with a SUH with no other significant finger tip injury, treatment by trephining gives a good cosmetic and functional result.

References

1. Simon RR, Wolgin M. Subungual hematoma:Association with laceration requiring repair. Am J Emerg Med 1987;5:302-4.
2. Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: A prospective study. Am J Emerg Med 1991;9:209-210.
3. Meeks S, White M. Subungual haematomas: is simple trephining enough? J Acc Emerg Med 1998;15:269-271.
4. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am] 1999;24:1166-1170.