10.08 Subungual Ecchymosis
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agk's Library of Common Simple Emergencie

Presentation
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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:
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- 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:
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- Do not perform a trephination of the nail.

Discussion:
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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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