Have you ever slammed your finger in a car door? Ever hit your finger while hammering? Ever dropped something on your toe? You know the excruciating pain that that causes; the feeling that your entire heart is crammed into the tip of your finger (or toe) and it might just burst from the pressure, but it doesn’t, so there is no relief.
In Wayne Simmonds case, a puck shot by Claude Giroux made a beeline for the tip of his finger. Yeah, he knows the feeling. The medical term for these black and blue nails is subungual hematoma. This is way more than a simple bruise, it’s a pool of blood that collects in between the nail and the nail bed. It’s a pool of blood that feels like it may as well be a raging river trying to burst forth from a dam.
The nail bed that lies beneath the nail has a rich blood supply that provides adherence to the nail and the blood supply give the nail bed that pink coloration. The tips of the fingers are also rich with nerve fibers, so the hematoma causes pressure in this small, contained area, which results in an exquisite amount of pain.
Subungual hematomas are generally the result of trauma to the nail area (like getting hit with a puck) that in turn causes blood to accumulate under the nail. The pool of blood produces pressure and severe, throbbing pain that is only relieved with time, or with decompression by putting a hole in the nail. Lucky for us, we were privy to see this procedure.
The decompression, called trephination, puts a hole in the nail to allow the blood to drain, without cutting or damaging the nail bed. There are a few ways to accomplish this. If you have access to a handheld electric cautery tool, it can be done just as we saw. It can also be done using a large gauge needle to drill through the nail or by heating a paperclip until it is red-hot and burning through the nail. This procedure can be done at home, but should be done by experienced medical personnel or athletic trainer.
Trauma can also sometimes result in a fracture, or break in the bone at the tip of the finger, so x-rays should be taken to see if there is a break. If the bruising and pain are not severe or the hematoma is less than 25% of the area of the nail, decompression is not necessary. Sometimes if the amount of blood that forms under the nail is excessive, the nail may be removed to check for lacerations or cuts in the nail bed. These lacerations generally will require suturing to repair.
Another cause for black nails is bruising or slight bleeding under the nail from repetitive trauma of the top of the shoe striking the nail with each step or the toe sliding forward into the end of the shoe. I see this commonly in runners training for marathons and in highly competitive runners training for shorter distance races but at high intensity and volume. These nail injuries are generally not painful and decompression will not help. A black spot under the nail could also be a melanoma. If you have a dark spot under the nail that does not go away, you need to see a doctor.
After a subungual hematoma forms, treatment should consist of ice and elevation above the level of the heart. If the hematoma is decompressed, the area needs to be covered and kept clean to prevent infection. The nail may fall off during the week following hematoma drainage but should grow back.
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