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PATIENT STORY

A 22-year-old woman dropped an iron on her toe the day before she visited our free clinic. Her toe was painful at rest and worse when walking (Figure 204-1). This subungual hematoma needed to be drained, and we did not have an electrocautery unit. A paperclip was bent open and held in a hemostat and heated with a torch. With some pressure it pierced the patient's nail plate and the blood spontaneously drained (Figures 204-2 and 204-3). This relieved the pressure and gave the patient immediate pain relief. The remaining old blood was drained with a little pressure on the proximal nail fold (Figure 204-4). Although we were concerned about a possible underlying fracture, the patient did not have health insurance and chose to postpone an X-ray. Her toe healed well and no radiographs were ever taken. (Story by Richard P. Usatine, MD.)

FIGURE 204-1

Acute subungual hematoma 1 day after dropping an iron on her toe. It was painful at rest and worse when walking. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 204-2

A paperclip was held in a hemostat and heated with a torch to pierce the patient's nail plate in order to relieve the subungual hematoma. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 204-3

The hot paper clip formed a nice hole in the nail plate, and the blood drained out spontaneously. This relieved the pressure and gave the patient immediate pain relief. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 204-4

After the nail plate is pierced, the blood drains easily with a little pressure on the proximal nail fold. (Reproduced with permission from Richard P. Usatine, MD.)

INTRODUCTION

Subungual hematoma (blood under the fingernail or toenail) is a common injury. It is typically caused by a blow to the distal phalanx (e.g., smashing with a tool, crush in a door jamb, stubbing one's toe). The blow causes bleeding of the nail matrix or bed with resultant subungual hematoma formation. Patients usually present because of throbbing pain associated with blue-black discoloration under the nail plate. Subungual hematomas may be simple (i.e., the nail and nail fold are intact) or accompanied by significant injuries to the nail fold and digit.1 The patient may not be aware of the precipitating trauma, because it may have been minor and/or chronic (e.g., rubbing in a tight shoe).

EPIDEMIOLOGY

Subungual hematoma is a common childhood and ...

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