Subungual hematoma

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Subungual hematoma
Other namesRunner's toe, tennis toe, skier's toe
Subungal hematoma of the finger.jpg
Subungal haematoma of the fourth finger
Specialty Internal medicine, Podiatry
Symptoms Discoloration of nail, pain
Risk factors Poorly fitting foot wear, overtraining particularly hiking and running
TreatmentUsually unmerited, blood drainage or nail removal in serious cases
Prognosis Usually self-resolving as nail grows out
Subungal haematoma of a toe Hematomasubungual.png
Subungal haematoma of a toe

A subungual hematoma is a collection of blood (hematoma) underneath a toenail or fingernail. It can be extremely painful for an injury of its size, although otherwise it is not a serious medical condition.

Contents

Nature

A laceration of the nail bed causes bleeding into the constricted area underneath the hard nail plate. [1] The blood pools under the nail, giving a reddish, brownish, blueish, or grey/blackish discoloration. The blood puts pressure to the nailbed causing pain which can be throbbing in quality and disappears when the pressure on the nail bed is relieved. [2]

Subungual hematomas typically heal without incident, though infection may occur. The pressure of the blood blister may cause separation of nail plate from the nail bed (onycholysis), but the nail should not be pulled off, as this can cause scarring of the nailbed and deformed nails. [3] Nail discolouration may last some months. [4]

The nail plate may also become thicker and more brittle as a result of the injury (onychochauxis). The deformed nail plate will gradually grow out and be replaced by a new, normal-appearing one in several months' time. Infrequently, the nail may become painful and require surgical drainage. [5]

Causes

Right: Shoe is loose, slides. Center: Too little ease for foot to extend. Left: Proper fit Preventing black toenail subungual hematoma.svg
Right: Shoe is loose, slides. Center: Too little ease for foot to extend. Left: Proper fit
A foot which has lost a toenail, due to running injuries exacerbated by poorly-fitting shoes, badly-cut nails, and mild Morton's toe Runners toe.jpg
A foot which has lost a toenail, due to running injuries exacerbated by poorly-fitting shoes, badly-cut nails, and mild Morton's toe

The condition is caused by a traumatic injury, such as slamming a finger in a door, [6] or from sports activities, especially those involving sudden accelerations, such as soccer, basketball, and tennis, or going downhill, such as running or hiking rugged terrain, and ill-fitting footwear. [4] [3] [7] :52,135

Repeatedly thrusting the toes against a shoe's toe box can cause a subungual hematoma called jogger's toe, [8] runner's toe, or black toenail. In a marathon, several percent of runners may be affected. [4] Wearing footwear which fits helps prevent runner's toe. [4]

If the shoe is too loose on the midfoot, the foot can slide forwards in the shoe, especially when going downhill. This may jam the toes into the end of the toebox. [4] If the foot is sliding forwards because the shoe is too loose around the midfoot, it may be restrained by lacing the shoe carefully, or placing bulky padding between the tongue and the lacing, or by wrapping a strap in a figure-eight around the foot and ankle (image). [7] :86–87,128,142 Excessively tight or uneven fit around the midfoot may, however, cause tendon problems. [7] :125[ better source needed ]

Separately, if there is not enough space around the toes, the toes will also hit the toebox repeatedly. [4] Feet become longer and wider when weight is put on them, because the arches flatten, and the toes also splay and bend. [7] :p15,18,72–73 At the end of a long journey on foot, the arches flatten, the metatarsals spread, and the foot swells more than after a short one. [7] :52 The toes also need vertical space; a toe cap which is low enough to press on the top of the toe may also cause bruising under the nail, especially if the toe cap is stiff. If the toebox is pointed, the toes may be wedged forwards into the area with inadequate height. [7] :52–53,135

Toenails which protrude unevenly may concentrate force on the toenail; properly-cut nails are therefore also important. [4]

Some susceptible runners may also have Morton's toe. In this variant of human foot anatomy, the second toe extends further out than the great toe. This can make it harder to find shoes with adequate space around the toes.[ citation needed ]

Treatment

Subungual hematomas can resolve on their own, without treatment being necessary. [4] If they are acutely painful, [9] they may be drained. [5]

Subungual hematomas are treated by either making a hole through the nail into the hematoma (trephining) within 48 hours of injury, draining the blood and releasing the pressure, [5] or, less conservatively, by removing the entire nail. [10]

In a hospital or medical setting, trephining is generally accomplished by using an electrocautery device or an 18-gauge needle. The hole is covered with sterile dressing and must be kept dry afterwards. [5]

Removal of the nail is typically done when the nail itself is disrupted, a large laceration requiring suturing is suspected, or a fracture of the tip of the finger occurs. Although general anesthesia is generally not required, a digital nerve block is recommended if the nail is to be removed.[ citation needed ] For trephination, the block is often more painful than the procedure. [5]

Complication rates from both forms of treatment are low, and the nail generally recovers to a normal appearance. [9]

See also

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Toe</span> Digit of a foot

Toes are the digits of the foot of a tetrapod. Animal species such as cats that walk on their toes are described as being digitigrade. Humans, and other animals that walk on the soles of their feet, are described as being plantigrade; unguligrade animals are those that walk on hooves at the tips of their toes.

<span class="mw-page-title-main">Nail (anatomy)</span> Hard keratin protection of digit

A nail is a protective plate characteristically found at the tip of the digits of all primates, corresponding to the claws in other tetrapod animals. Fingernails and toenails are made of a tough rigid protein called alpha-keratin, a polymer also found in the claws, hooves and horns of vertebrates.

<span class="mw-page-title-main">Nail disease</span> Medical condition

A nail disease or onychosis is a disease or deformity of the nail. Although the nail is a structure produced by the skin and is a skin appendage, nail diseases have a distinct classification as they have their own signs and symptoms which may relate to other medical conditions. Some nail conditions that show signs of infection or inflammation may require medical assistance.

<span class="mw-page-title-main">Hematoma</span> Localized bleeding outside of blood vessels

A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is benign and is initially in liquid form spread among the tissues including in sacs between tissues where it may coagulate and solidify before blood is reabsorbed into blood vessels. An ecchymosis is a hematoma of the skin larger than 10 mm.

<span class="mw-page-title-main">Athlete's foot</span> Skin infection caused by fungus

Athlete's foot, known medically as tinea pedis, is a common skin infection of the feet caused by a fungus. Signs and symptoms often include itching, scaling, cracking and redness. In rare cases the skin may blister. Athlete's foot fungus may infect any part of the foot, but most often grows between the toes. The next most common area is the bottom of the foot. The same fungus may also affect the nails or the hands. It is a member of the group of diseases known as tinea.

<span class="mw-page-title-main">Diseases of the foot</span> Medical conditions affecting the human foot

Diseases of the foot generally are not limited, that is they are related to or manifest elsewhere in the body. However, the foot is often the first place some of these diseases or a sign or symptom of others appear. This is because of the foot's distance from the central circulation, the heart and its constant exposure to pressures from the ground and the weight of the body.

<span class="mw-page-title-main">Ingrown nail</span> Medical condition

An ingrown nail, also known as onychocryptosis from Greek: ὄνυξ 'nail' and κρυπτός 'hidden', is a common form of nail disease. It is an often painful condition in which the nail grows so that it cuts into one or both sides of the paronychium or nail bed. While ingrown nails can occur in the nails of both the hands and the feet, they occur most commonly with the toenails, and for the most part are only problematic and painful on the big toe.

<span class="mw-page-title-main">Cauliflower ear</span> Permanent deformity caused by physical trauma to the ear

Cauliflower ear is an irreversible condition that occurs when the external portion of the ear is hit and develops a blood clot or other collection of fluid under the perichondrium. This separates the cartilage from the overlying perichondrium that supplies its nutrients, causing it to die and resulting in the formation of fibrous tissue in the overlying skin. As a result, the outer ear becomes permanently swollen and deformed, resembling a cauliflower, hence the name.

<span class="mw-page-title-main">Paronychia</span> Medical condition

Paronychia is an inflammation of the skin around the nail, which can manifest suddenly, often due to the bacterium Staphylococcus aureus, or gradually, typically caused by the fungus Candida albicans. The term originates from Greek: παρωνυχία, derived from para 'around', onyx 'nail', and the abstract noun suffix -ia.

<span class="mw-page-title-main">Onychomycosis</span> Medical condition

Onychomycosis, also known as tinea unguium, is a fungal infection of the nail. Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed. Fingernails may be affected, but it is more common for toenails. Complications may include cellulitis of the lower leg. A number of different types of fungus can cause onychomycosis, including dermatophytes and Fusarium. Risk factors include athlete's foot, other nail diseases, exposure to someone with the condition, peripheral vascular disease, and poor immune function. The diagnosis is generally suspected based on the appearance and confirmed by laboratory testing.

<span class="mw-page-title-main">Onychogryphosis</span> Medical condition

Onychogryphosis is a hypertrophy that may produce nails resembling claws or a ram's horn.

<span class="mw-page-title-main">Subungual exostosis</span> Medical condition

Subungual exostosis is a type of non-cancerous bone tumor of the chondrogenic type, and consists of bone and cartilage. It usually projects from the upper surface of the big toe underlying the nailbed, giving rise to a painful swelling that destroys the nail. Subsequent ulceration and infection may occur.

<span class="mw-page-title-main">Morton's toe</span> Type of brachymetatarsia affecting the big toe

Morton's toe is the condition of having a first metatarsal bone that is shorter than the second metatarsal. It is a type of brachymetatarsia. This condition is the result of a premature closing of the first metatarsal's growth plate, resulting in a short big toe, giving the second toe the appearance of being long compared to the first toe.

<span class="mw-page-title-main">Barefoot running</span> Running with minimalist or no shoes

Barefoot running, also called "natural running", is the act of running without footwear. With the advent of modern footwear, running barefoot has become less common in most parts of the world but is still practiced in parts of Africa and Latin America. In some Western countries, barefoot running has grown in popularity due to perceived health benefits.

Malalignment of the nail plate, also known as congenital malalignment of the great toenails or congenital malalignment syndrome, is a congenital malalignment of the nail of the great toe, and is often misdiagnosed although it is a common condition. It most commonly affects the hallucices. The nail might be discolored and develop infections. If the misaligned nail becomes embedded in the lateral nail fold it can cause pain, inflammation and erythema.

<span class="mw-page-title-main">Corn (pathology)</span> Distinctively shaped callus of dead skin

A corn or clavus is an often painful, cone-shaped, inwardly directed callus of dead skin that forms at a pressure point near a bone, or on a weight-bearing part of the body. When on the feet, corns can be so painful as to interfere with walking. The visible portion of the corn tends to be more-or-less round, but corns are defined by having a hard tapering root that is directed inward, and pressure on the corn pushes this root deeper into the flesh Pressure corns usually occur on thin or glabrous skin surfaces, especially on the dorsal surface of toes or fingers, but corns triggered by an acute injury may occur on the thicker skin of the palms or bottom of the feet.

<span class="mw-page-title-main">Vibram FiveFingers</span> Brand of minimalist shoes

The Vibram FiveFingers are a type of minimalist shoe manufactured by Vibram, originally marketed as a more natural alternative for outdoor activities. The footwear is meant to replicate being barefoot and has thin, flexible soles that are contoured to the shape of the human foot, including visible individual sections for the toes. The company settled a lawsuit in 2014 alleging false health claims and set aside $3.75 million to pay refunds of up to $94 to anyone who had purchased the product since March 21, 2009.

<span class="mw-page-title-main">Toe box</span> Part of a shoe

The toe box is the section of footwear that surrounds the toes on closed-toe shoes. Toe boxes that are too tight can cause injuries and foot deformities, whereas wider toe boxes may be used to treat or prevent common foot conditions such as Morton's neuroma. Toe boxes come in a variety of shapes and styles of construction, some of which are a matter of fashion, and some of which are designed for specialized functions.

<span class="mw-page-title-main">Broken toe</span> Medical condition

A broken toe is a type of bone fracture. Symptoms include pain when the toe is touched near the break point, or compressed along its length. There may be bruising, swelling, stiffness, or displacement of the broken bone ends from their normal position.

References

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  3. 1 2 "3 Tips to Protect Your Toenails If You're a Hard-Core Runner". Health Essentials from Cleveland Clinic. 3 December 2015.
  4. 1 2 3 4 5 6 7 8 Mailler, EA; Adams, BB (August 2004). "The wear and tear of 26.2: dermatological injuries reported on marathon day". British Journal of Sports Medicine. 38 (4): 498–501. doi:10.1136/bjsm.2004.011874. PMC   1724877 . PMID   15273194.
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  6. "Subungual Hematoma: Care Instructions". myhealth.alberta.ca.
  7. 1 2 3 4 5 6 Munson, Edward Lyman (1912). The soldier's foot and the military shoe; a handbook for officers and noncommissioned officers of the line. Menasha, Wis.: Press of the George Banta publishing company. (this is the publication of a four-year review into the footwear of the US military by the Army Shoe Board, of which the author, a physician and senior officer of the United States Army Medical Corps, is president.
  8. Mailler, E A; Adams, BB (2004). "The wear and tear of 26.2: dermatological injuries reported on marathon day". British Journal of Sports Medicine. 38 (4): 498–501. doi:10.1136/bjsm.2004.011874. PMC   1724877 . PMID   15273194.
  9. 1 2 Dean, B; Becker, G; Little, C (2012). "The management of the acute traumatic subungual haematoma: a systematic review". Hand Surgery. 17 (1): 151–4. doi:10.1142/S021881041230001X. PMID   22351556.
  10. "Primary Care Procedures: Trephination of Subungual Hematoma". consultantlive. UBM Medica, LLC. Archived from the original on 21 August 2016. Retrieved 30 July 2016.