Subungual hematoma is a consequence of a mechanical injury to the nail phalanx of the upper or lower limb, in which hemorrhage occurs in the soft tissues of the nail bed. The damage is characterized by pain of varying degrees of intensity, local fever, edema, the appearance of red, and then cyanotic and black staining of the nail plate. The diagnosis is established on the basis of anamnesis and clinical picture. In most cases, no treatment is required. Detachment of the nail plate, laceration of soft tissues is an indication for surgical treatment of the damaged area, suturing and bandaging.
T14.0 Superficial trauma of an unspecified body area
Synonymous names are used to denote pathology: bruise under the nail, “blue nail”. During life, every person receives such bodily injury, sometimes repeatedly. More often injuries are registered in men of working age. The peak of injuries occurs during the warm season and the holiday period, when most people are engaged in construction and repair, work on household plots, and actively relax in nature. The vast majority of cases of subarticular hemorrhages remain out of sight of doctors, as patients often consider the damage insignificant and simply ignore it.
Physical impact and a number of predisposing factors are important in the development of subungual hematomas. Thus, the risk of bleeding in response to a minor injury increases in patients taking anticoagulants. Patients with diabetes mellitus and other diseases, in which polyneuropathy develops, tactile and pain sensitivity are disturbed, notice the damage late. The main causes of the appearance of subungual hematomas include:
- A sharp directional blow. A contusion of the terminal phalanx, depending on the strength of the impact, can lead to damage to skin vessels, crushing of tissues, the appearance of a torn wound, bone fracture. Each of these injuries is characterized by accumulation of blood under the nail. Therefore, any injury requires medical attention.
- Prolonged mechanical impact. Wearing shoes that are incorrectly matched in size and completeness leads to injury to the nail plates and the skin located under them. In fact, a corn develops, which is filled with serous fluid or blood. In this case, the nail plate may completely or partially peel off.
At the heart of the development of a subungual hematoma is a violation of the integrity of the vessels. The spilled blood permeates the tissues, including the nail plate. If the volume of blood is insignificant, the structure of soft tissues is preserved. If the volume and rate of bleeding are significant, then under the pressure of blood, soft tissues are stratified with the formation of a cavity. Subungual hematoma formed under the skin at the well or in the area of the nail bed, as the nail grows, moves in the distal direction. The blood pressure in the hematoma area irritates the nerve endings, which provokes pain. A sharp increase in the volume of the hematoma leads to the formation of a sub-elbow space or a breakthrough of blood at the nail rollers.
The blood that has soaked the soft tissues gradually resolves. Staining of the nail plate is irreversible. Over time, the blood clot loses moisture, becomes dark blue at first, then turns black. In both cases, a spot is formed that moves to the free edge of the nail plate.
Often the concepts of “hematoma” and “bruise” are used synonymously, but this is not entirely true. The differences between these two conditions relate to the mechanisms of injury, the clinical picture of the disease, the duration of forced temporary disability due to limb injury, and medical approaches to treatment.
- Subcutaneous bruising. It develops due to the impregnation of the skin and subcutaneous tissue with blood from damaged vessels. As a rule, it is formed with a slight impact and is characterized by unexpressed symptoms. The patient’s condition quickly normalizes, the functioning of the limb is restored.
- Subcutaneous hematoma. It differs from a bruise by tissue stratification with the formation of a blood-filled cavity. Hemorrhagic impregnation also takes place, however, the volume of blood spilled is much larger than with a bruise, which increases the likelihood of nail detachment and the development of other complications.
Characteristic signs of hemorrhage in the subcutaneous area that developed after injury are local hyperemia, fever, swelling, throbbing or bursting pains. The peak of the local temperature increase occurs 2-3 hours after the injury. On the 2-3 day, the pain subsides, the swelling begins to subside.
Immediately after the injury, the nail acquires a rich red or cherry-purple color. On the second or third day, the affected area turns blue, after another week or two it acquires an intense black color. The area of the nail soaked in blood gradually moves towards the nail edge and is cut off. Thus, the black spot can persist for 2-3 months.
In cases where the cause of injury is the wearing of uncomfortable shoes, minor soreness or discomfort may be noted. But more often, a change in the color of the nail plate becomes an accidental find during the implementation of foot care. Simultaneously with the color change, detached fragments of the plate, corn on the skin of the fingers in the area of the nail rollers are often detected.
Damage to the skin and the base of the nail leads to its deformation. The severity and duration of the deformation are determined by whether the growth zone has been affected. Normally, deformed areas are cut off with scissors during manicure. Trauma to the base of the nail plate leads to persistent deformation, which does not disappear with time. The appearance of a crack or chipped nail as a result of mechanical action creates conditions for the penetration of infection and the development of purulent inflammation of damaged tissues. Microorganisms multiply especially actively in the hematoma cavity. Insufficient care for the bruised phalanx can cause the development of panaritium.
In appearance, subungual hematoma have similar features to onychopathies in psoriasis, melanoma. The degree of damage to the finger on impact is not always obvious. In this regard, it is better to consult a surgeon, even if the injury does not seem serious. A comprehensive examination of a patient with a phalanx injury includes:
- General inspection. A subungual hematoma is indicated by the presence of previous mechanical action, an acute course with a rapid increase in symptoms. Palpation of the damaged area is painful. Drainage, which can be performed directly during an outpatient appointment, gives a quick effect.
- X-ray examination. An X-ray of the finger is performed in order to detect a violation of the integrity of the bones and joints of the limb. According to the X-ray data, it is possible to judge the presence of a fracture, but it is impossible to draw unambiguous conclusions about the degree of damage to soft tissues (skin, tendons, muscles), the volume of the hematoma.
Medical tactics are determined by the severity of the injuries. Indications for seeking medical help are intense, unbearable pain in the area of the injured phalanx and the size of the hematoma over ¼ of the nail area. The scope of medical care is determined by the surgeon based on the examination data and X-ray:
- First aid. Proper care of the damaged phalanx allows you to quickly relieve pain, stop or slow down bleeding, and prevent peeling of the nail plate. Immediately after the injury, it is necessary to lower the finger into a container with cold water for 15-20 minutes. Then, if there is an open wound, treat the damaged area with an antiseptic solution and apply a bandage.
- Drainage of hematoma. The nail plate above the hematoma is pierced with a needle or burned with a thermal router. The outflow of blood through a small hole leads to a decrease in pressure on the tissues, a decrease in the intensity of pain. A drained subcutaneous hematoma resolves faster, which is significant for patients who need to have no cosmetic defects on their hands.
- Removal of the nail plate. The nail plate is removed partially or completely when it is detached from the nail bed. Attempts to save the nail can lead to adverse consequences: detached fragments disrupt the normal functioning of the finger, can cause additional injury in case of accidental separation.
- Surgical treatment of the wound. Tissue crushing, laceration, and bone fracture require a PHO, which includes removal of non-viable fragments, suturing, and drainage. The purpose of medical manipulations is to create optimal conditions for healing, prevention of violations of the function of the foot or hand, purulent-septic complications.
- Bleaching of a damaged nail. The nail plate soaked in blood grows back within a few months. To eliminate a cosmetic defect in one procedure allows injectable injection of special bleach. In this case, the black spot is completely discolored. Bleaching preparations applied externally do not give a noticeable effect.
Prognosis and prevention
In the vast majority of cases, a subungual hematoma passes on its own without treatment. Within a month or two, only a cosmetic defect in the form of a dark spot on the nail reminds of the injury. As a preventive measure, it is recommended to observe safety precautions and accuracy when performing work, closing doors, moving cargo. Properly selected sports and casual shoes allow you to keep your feet healthy. To protect the fingers, it is recommended to use special work gloves and various devices that reduce the likelihood of damage to the upper extremities (clamps, clamps, manipulators).