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Subungual Hematoma

Two Evacuation Procedures

Vol. 17 • Issue 1 • Page 20

Trauma to the nail plate that causes bleeding beneath the nail results in a subungual hematoma and digit pain.

This collection of blood between the nail bed and fingernail should be removed within 4 hours of the injury, if possible. Outside this time frame, clotting may occur and make hematoma evacuation difficult.

Contraindications to subungual hematoma evacuation include hematoma over more than 50% of the nail surface, a crushed or fractured nail, a history of poor wound healing, and suspected distal phalanx fracture.


First, inspect the nail for contraindications to evacuation. Palpate for tenderness beyond the nail bed.

Determine the vascular and neurologic status of the digit. Perform active and passive range of motion of the joint, and test for instability of the digit's joint.

If you suspect a fracture or if the hematoma encompasses more than 25% of the nail, order an x-ray.

If a fracture or joint instability is present, refer the patient to an orthopedic specialist for more thorough evaluation.

Subungual hematoma excision is performed to relieve pain and prevent possible infection. There are two methods, the cautery technique and the paper clip technique.

Procedure Instructions

The equipment necessary for both procedures is listed in the table.

If the patient has not had a tetanus booster within the last 5 years, administer one before excision.

For each method, have the patient wash his or her hands with antiseptic skin cleanser. Then soak the affected finger in Betadine with 0.9% sodium chloride for 5 to 10 minutes.

Position the patient with the affected finger easily accessible on 4 x 4 gauze, and put on gloves. Stabilize the finger.

Cautery Technique

For the cautery technique, start by activating the cautery. When the tip becomes red hot, position it at a 90-degree angle to the injury, and apply firm, gentle pressure directly over the middle of the hematoma.

At first, you will feel resistance. When the needle burns through the nail, resistance will cease. Remove the cautery from the nail, and allow blood to drain.

Apply gentle pressure to the nail to assist with blood evacuation.

Paper Clip Technique

For the paper clip technique, open up the paper clip. Holding it with hemostats, heat the tip of the paperclip until it is red hot.

Position the paper clip at a 90-degree angle to the injury, and apply gentle pressure directed over the middle of the hematoma (see illustration above).

When resistance ceases, remove the paper clip and allow the blood to drain from the nail bed.

Postprocedure Instructions

After the blood has drained, instruct the patient about the following points for postprocedure care:

• Keep the wound clean and dry.

• Observe for sign and symptoms of infection. These signs and symptoms include an increase in pain after 24 hours, an increase in wound temperature, redness or swelling, yellow or greenish drainage, or foul odor.

• Soak the affected finger three times per day in warm salt water for 2 days. Create this salt water solution by adding 1 teaspoon of salt to a quart of water.

• Take acetaminophen or ibuprofen every 4 to 6 hours as needed for pain.

Antibiotics are usually not required, and most cases heal well after this procedure.


Colyar MR, Ehrhardt C. Ambulatory Care Procedures for Primary Care Providers. Philadelphia, Pa: F.A.Davis; 2003.

Pfenninger JL, Fowler GC. Procedures for Primary Care Physicians. St. Louis, Mo.: Mosby; 2003.

Hoffman D, Shaffer T. Management of common finger injuries. Am Fam Physician. 1991;43(5):1594-1607. 

Margaret Colyar is a family and pediatric nurse practitioner who is a member of the ADVANCE for Nurse Practitioners editorial advisory board. She practices at Ideal Image in Fort Myers, Fla.

Equipment Needs

Both Methods

•Antiseptic skin cleanser

•Gloves (nonsterile)

•Basin (sterile)

•Antibacterial soap


•0.9% sodium chloride (sterile)

•4 x 4 gauze (sterile)

Cautery Method

•Battery-powered cautery device

Paper Clip Method

•Cigarette lighter or matches

•Paper clip (medium or large)

•Hemostat (sterile)


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