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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 196-1). 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 196-2 and 196-3). 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 196-4). 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 196-1

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

Figure 196-2

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. (Courtesy of Richard P. Usatine, MD.)

Figure 196-3

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. (Courtesy of Richard P. Usatine, MD.)

Figure 196-4

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

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).

Subungual hematoma is a common childhood and adult injury.

  • The injury causes bleeding of the nail matrix and nail bed, which results in subungual hematoma formation (Figures ...

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