10.08 Subungual Ecchymosis

agk’s Library of Common Simple Emergencies

Presentation

The patient will have had a crushing injury over the fingernail; getting it caught between two heavy objects for example, or striking it with a hammer. The pain is initially intense, but rapidly subsides over the first half hour, and by the time he is examined only mild pain and sensitivity may remain. There is a light brown or light blue-brown discoloration beneath the nail.

What to do:

• Get an x ray to rule out a possible fracture of the distal phalangeal tuft.
• Apply a protective fingertip splint, if necessary for comfort.
• Explain that you are not drilling a hole in the patient’s nail, because there is not a subungual hematoma to evacuate. Inform the patient that, in time, he may lose the fingernail, but that a new nail will replace it.

What not to do:

• Do not perform a trephination of the nail.

Discussion:

Unlike the painful space-occupying subungual hematoma, the subungual ecchymosis only represents a thin extravasation of blood beneath the nail or a mild separation of the nail from the nailbed. Doing a trephination will not relieve any pressure or pain, and may indeed cause excruciating pain, as well as open this space to possible infection. The patient’s familiarity with nail trephination (above) may give him the erroneous expectation that he should have his nail drilled.

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