Subungual hematoma: nail bed repair or nail trephination? A systematic review

Background Nail bed injuries are a major cause of presentation in the emergency department, accounting for 15 to 24% of all fingertip injuries, but management lacks consensus. Different methods have been published for the treatment of subungual hematoma, which leads to an important controversy among hand surgeons. The objective of this study was to conduct a systematic review to compare nail trepanation with nail avulsion and matrix repair, deciding which is the most appropriate according to each injury pattern. Methods We carried out a systematic review of the literature using MEDLINE via PubMed, Virtual Health Library, Embase, and Cochrane Library through September 2021. Inclusion criteria were journal articles published in the last 11 years (2010–2021) in English, French, Portuguese, and Spanish and conducted in humans. Case reports, case series studies, and pre-clinical studies were excluded, in addition to those which are still in progress, did not report primary outcome or full-text was not available. Results The search resulted in the screening of 599 records. Of these articles, 16 were eligible for the review. As shown in some literature reviews, the traditional approach to subungual hematoma is to remove the nail, analyze the sterile matrix, and repair the injury. According to many authors, this can depend on the size of subungual hematoma and if there is any fracture associated. On the other side, subungual hematomas also can be relieved by simple trephination, yielding good pain relief and satisfactory nail plate regeneration. Conclusions With our review, we can determine more accurate recommendations regarding the possible treatment for ungual complex injuries with subungual hematomas. In this sense, nail trephination alone is recommended whenever possible and nail removal with matrix repair is better when there is fracture or hematoma covers greater than 50%. In addition, small non-painful bruises do not require intervention, as knowing that it is incorporated into the nail and progressively migrates to the free edge of the nail plate. Level of evidence: Not ratable.