Evacuation of Subungual Hematoma With an 18-Gauge
How I Do It
Key words: subungual hematoma, needle aspiration, decompression
rush injury to the distal part of a finger or toe commonly produces a
painful subungual hematoma.The accumulation of blood under the nail
results in a bluish discoloration and intense pain caused by pressure,1,2
and prompt decompression of the hematoma results in immediate relief of the
symptoms. The most common method of treatment is nail trephination. For decades, physicians have used heated paper clips, heated needles, dental burrs,
fine-pointed scalpel blades, drills, cautery devices, or carbon dioxide lasers for
trephining.1-5 The authors evacuate subungual hematomas successfully and easily
with an 18-gauge needle in the emergency department.
Address correspondence to:
Yuan-Sheng Tzeng, MD
Division of Plastic and
Department of Surgery
Tri-Service General Hospital
National Defense Medical Center
No. 325, Section 2, Cheng-Gung
Taipei, 11490, Taiwan
From the Division of Plastic and
Reconstructive Surgery, Department
of Surgery, Tri-Service General
Hospital, National Defense Medical
Center, Taipei, Taiwan
Abstract: An injury to a finger or toe can result in a collection of blood
under the nail plate that, if unrelieved, can cause extreme discomfort
due to pressure. In this case, a 22-year-old man developed a subungual
hematoma of the right index finger due to a crush injury. Controlled nail
trephination was performed using an 18-gauge needle that penetrated
the nail plate without breaching the nail bed. The subungual hematoma was successfully drained, and there was a substantial relief in
pain immediately. This technique appears to be a quick and convenient
method of evacuating subungual hematomas with minimal discomfort
and minimal risk.
Chin-Ta Lin;Yuan-Sheng Tzeng, MD
Evacuation of Subungual Hematoma
With an 18-Gauge Syringe Needle
Disclosure: The authors disclose
no financial or other conflicts of
A 22-year-old male experienced a crush injury of his right index finger while
playing basketball. His immediate pain persisted and evolved into a severe throbbing pain coincident with the development of a blue/black hue of the entire
visible nail within 5 minutes. The patient presented to the authors’ emergency
department (Tri-Service General Hospital, National Defense Medical Center, Taipei,Taiwan) 2 hours later; physical examination revealed no breaks in the skin as
well as a severe point of tenderness on the dorsal nail.The diagnosis of subungual
hematoma was made.The nail was cleaned using alcohol and allowed to dry.The
pooled blood under the nail was visualized using a bright light and the central
part of the hematoma selected for evacuation. No local anesthesia was required.
The point of an 18-gauge needle was placed over the site of the hematoma
and twisted lightly between the index finger and the thumb (Figure 1A). With
this method, the needle acted as a drill, slowly penetrating the nail in an oblique
angle, between 45 and 60 degrees, with no pressure needing to be applied to
Vol. 26, No. 2 February 2014
Lin & Tzeng
obscure at first. In the late stage of the
process, the hematoma becomes more
widespread because of the progression
of the blood, peripherally between nail
plate and nail bed, due to the pressure.
Thus, the late lesions appear larger and
can be observed more easily. However,
in late cases, this progression may cause
secondary dystrophy if it reaches to the
matrix.6 Therefore, early treatment is important.
Figure 1. A: Lightly twist the point of an 18-gauge needle back and forth between the index finger and the thumb until a small amount of blood appears
at the tip of the needle. B: Normal appearance of a nail after decompression
of a subungual hematoma.
This procedure is a fast, simple, welltolerated technique that is particularly
successful for the treatment of subungual hematoma.The only instrument required is an 18-gauge needle and, because the needle is sterile, the risk of infection is minimal. It is cosmetically superior
to nail trephination because the nail plate is left intact. For
these reasons, the authors suggest this technique as an alternative to the traditional nail trephining methods.
the needle by the thumb and index finger. After 1 minute,
approximately 0.2 mL of blood appeared at the tip of the
needle and the patient had immediate pain relief. Due to the
shape of the needle, it had to be advanced a bit further after
blood was obtained to achieve continued evacuation of the
hematoma. The nail was then cleared of debris and blood
using alcohol and sterile gauze. Total evacuation of the hematoma was achieved (Figure 1B) by applying light pressure
to the nail. The patient did not complain of pain and had
only slight tenderness. Because of the prompt resolution of
the pain and absence of any deformity, no x-ray was ordered.
Subungual hematomas occur frequently after a crush
injury to a digit, and can cause extreme discomfort due to
the buildup of pressure under the nail plate. Drainage of the
hematoma provides immediate and lasting relief, whereas
analgesics only provide temporary relief. The pain incurred
by the current methods of drainage limit their applicability.
These methods include using a heated paper clip, electrocautery, or a presterilized needle to bore a hole in the nail
plate, as well as nail plate removal.1-5
The treatment of a simple subungual hematoma requires
subungual decompression, which is usually achieved by creating small holes in the nail plate.1-5 Draining the blood from
the nail plate with an 18-gauge needle is significantly less
painful than 1 injection of digital nerve block. Because the
needle causes little trauma and there are no nerves in the
nail plate, the patient feels minimal pain and tolerates the
procedure quite well; therefore, there is no need for anesthesia. In its early stage, the subungual hematoma is in a small
space with high pressure; therefore, the hematoma appears
The authors would like to thank the Civilian Administration Division of the Tri-Service General Hospital, National
Defense Medical Center,Taipei,Taiwan.
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