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Best evidence topic reports
Treatment of uncomplicated subungual haematoma
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  1. Nicola Batrick, Specialist Registrar,
  2. Kambiz Hashemi, Consultant,
  3. Ramzi Freij, Consultant,
  4. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}man.ac.uk

    Abstract

    A short cut review was carried out to establish whether nail removal and nail bed repair is better than simple trephining in patients with significant subungual haematoma. Altogether 312 papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

    http://dx.doi.org/10.1136/emj.20.1.65

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      Report by Nicola Batrick, Specialist Registrar
 Checked by Kambiz Hashemi and Ramzi Freij, Consultants

      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.

      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]?

      Search strategy

      Medline 1966–10/02 using the OVID interface. [subungual hematoma.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 four papers are shown in table 5.

      View this table:
      Table 5

      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 seems from the studies quoted that simple trephining of the nail in an uncomplicated subungual haematoma with no other significant finger tip injury gives good cosmetic and functional results.

      ▸ CLINICAL BOTTOM LINE

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

      Report by Nicola Batrick, Specialist Registrar
 Checked by Kambiz Hashemi and Ramzi Freij, Consultants

      References

      1. Simon RR, Wolgin M. Subungual hematoma: Association with laceration requiring repair. Am J Emerg Med1987;5:302–4.
        OpenUrlCrossRefPubMedWeb of Science
      2. Seaberg DC, Angelos WJ, Paris PM. Treatment of subungual hematomas with nail trephination: A prospective study. Am J Emerg Med1991;9:209–10.
        OpenUrlCrossRefPubMedWeb of Science
      3. Meek S, White M. Subungual haematomas: is simple trephining enough? J Accid Emerg Med1998;15:269–71.
        OpenUrlAbstract/FREE Full Text
      4. Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg [Am]1999;24:1166–70.
        OpenUrlCrossRefPubMed