Subungual Hematoma

If you had just slammed your finger on your car door and the pain is unbearable and the nail has turned black and blue, then you are likely to have Subungual hematoma. The nail hematoma is seldom serious but always painful.
Also called Runner's Toe or Tennis Toe, Subungual Hematoma is a collection of blood under the fingernail or toenail.

This may have been caused by an injury such as slamming the nail in a door or dropping a heavy object on the nail. Subungual Hematoma can occur when blood thinning or cancer treatment medicines are consumed or you have an autoimmune condition. Subungual Hematoma can be extremely painful for an injury of its size although otherwise it is not a serious medical condition.

Signs and symptoms

• A discoloration in red or purple or maroon under the nail after an injury.
  
• Throbbing and intense pain; pressure generated between the nail and the nail bed where the blood collects causes this pain.
  
• Swelling in the affected nail or toe.
  
• Tender to the touch.
  

Causes

Subungual hematomas commonly occur after a crush type of injury at the tip of the finger or toe – hitting your finger with a hammer, dropping a heavy object on your toe or closing your finger in a door. Subungual Hematoma may be caused by ill fitting shoes and insufficient space for the toes.

The condition also results from slamming a finger in a door or from sports activities such as climbing or hiking in a rugged terrain. Due to running injuries, a foot might have lost a toenail and this is exacerbated by poorly fitting shoes.

Subungual Hematoma that occurs from repetitive thrusting of the longest toe into a shoe's toe box is called jogger's toe or runner's toe. Here bleeding occurs from the nail bed underlying the nail plate.

Runners toe is caused by downward pressure or horizontal separation of nail plate from nail bed. Repetitive traumatic injury leads to bleeding and blood gets pooled underneath the toe nail. The deformed nail plate gradually grows out and is replaced by new nail plate several months later. Sometimes the toe may become painful and require surgical drainage.

Treatment of Subungual Hematoma

A small hole is made in the nail to drain the blood. This will decrease pain and swelling. Following commonly used methods for draining hematoma include:

Cautery, a battery operated device used to burn a hole in the nail until the blood is reached and drained out of the hole. In case the patient is using artificial acrylic nails which might be flammable, this method should not be used.

A large diameter needle is used to drill or bore into the nail to create a hole to allow the blood to drain out.

Nail removal may be done if the nail is damaged. The doctor may also have to repair the tissue under the nail. Although anesthesia is generally not required, a digital nerve block is recommended to be performed if the nail is to be removed.

A splint may be placed on the finger or toe to prevent movement and protect the area while it heals. Subungual hematoma may typically heal without incident, although infection of the nail may occur.

Caring for Subungual hematoma

Keep injured finger or toe dry as long as directed.

Trim nails gently if it begins to fall off in pieces. This may decrease risk for catching the nail on an object or ripping it off.

Wear shoes that are comfortable and fit correctly to prevent injury to the toe.

Ice is used to elevate the affected finger. Place ice wrapped in a towel over the painful area for as long as directed and then elevate hand or foot on pillows above the level of the heart to help decrease swelling and pain.

If the nail was removed by the injury and the nail bed is not cut, then it is recommended to have the following home treatment done until the nail bed begins to be less sensitive, usually in a week to ten days. Twice daily soak with antibacterial soap and water for ten to fifteen minutes. After soaking, apply a topical antibiotic ointment and a dry sterile bandage.

Prevention

Exert caution when dealing with heavy objects. While on some high risk jobs, used steel toed shoes. Watch children's hands while opening and closing doors. Give full attention to the task on hand. Finger injuries often happen when the person using the hammer is distracted. In case of heavy objects, find people who can carry them – instead of dropping them on your toes.

Ingrown Toenail

A common foot problem, ingrown toenails or onychocryptosis can be very painful and need to be treated by a chiropodist. If a splinter or the whole nail exert pressure against the skin on any or both sides of the nail, it will result in an ingrown toenail. If this pressure is prolonged, it can cause swelling, infection, and irritation of the skin and pain. An injury to the toe can also cause acute ingrown toenails. In a chronic condition, it lasts for a long time. Though it is the large toe that is affected normally, the other toes are sometimes affected.

Ingrown toenail can be the result of an abnormality of the soft tissue on the side of the nail. It may also be a result of laxity of the skin due to certain rare diseases. Wearing tight fitting shoes normally leads to soft tissue abnormality. Overcrowding of the toes because of these shoes will result in pushing the soft tissue against the sides of the nail. Nail abnormalities is another widespread factor for ingrown toenails.

During the developmental stages of the foot, wearing shoes that are very narrow or short can lead to bunching of the toes that causes the nail to curl into the skin and cause ingrown toenails. If a person cuts the toenail short and curved, it may result in the edges turning in. Sometimes advancing age, poor blood circulation at the extremities due to blockage in blood vessels may also cause curved nails. Ingrown toenails can also be caused by bone spurs beneath the nail, or a direct hit on the nail, or due to multiple infections and certain drugs like Indinavir; but these are not very common.

Trauma that is caused by stubbing the toenail or dropping heavy objects on the toe will injure the flesh and this condition makes the nail to grow irregularly. This nail may also press into the flesh. For some people, there is a tendency of the nails to grow inwardly because they are genetically prone to nail problems and nail deformities. Ingrown toenails are categorized as three stages.

I Stage: Painful to the touch, the skin on both sides of the nail appears red due to inflammation or irritation. This condition may not be due to infection.

II Stage: The skin may bulge over the side of the nail and this may be due to infection. There may be oozing of a clear fluid or pus in the affected area.

III Stage: The infection may try to heal itself if the infection had been there for a prolonged time. By forming granulation tissue, the infection tries to heal, but that will add to the problem by making the tissues bleed easily. These tissues also move over the nail edge.

Clinically ingrown toenails can be diagnosed by looking at their appearance. The presence of pus indicates bacterial infection and should be determined by a culture test. Infections might have spread to the bone or joint space at times and with a x-ray, the physician can rule out this possibility which is rare. Diabetics are more prone to this condition and so should pay proper attention to their feet. These people lose sensation in their feet if they develop peripheral neuropathies.

The treatment of ingrown toenails depends upon its stage. Warm soaks, cutout shoe and elevation of the toenail with a cotton swab are some of the measures taken for stage one. Though the symptoms may improve soon, there will be complete cure only after a few weeks. Along with warm soaks, oral antibiotics are given for stage two ingrown toenails. Surgical options are there to remove a portion of the toenail if it is extremely painful.

If the condition has reached the third stage then partial or full toenail removal is the only way. This procedure is known as partial nail avulsion (PNA). This procedure involves removal of the section of the ingrown nail after injecting the toe with a local anesthetic. It will take 4-6 weeks for the site to heal after this surgery which is very common and painful.

How to prevent ingrown toenails?

1. Cut the nails straight across; do not cut the nails along a curve or very short.
2. Use foot wear that fits well. Shoes that are small in size or width will aggravate any problem that already exists with a toenail.
3. Prevent injuries to the toes by wearing shoes almost always during working or playing.
4. It is a myth that a V cut at the end of the ingrown nail will help the edge of the nail grows together. Only the growing area at the base of the toe determines the shape of the nail and it is not the end of the nail that determines it. It takes almost up to one year for a toenail to grow and this method will in no way hurry the growth.

Fungal nail infection

Fungal nail infections are most often noticed on toenails and are accompanied by fungal feet infection. Nails can be infected by fungi due to nail injury, nail disease, over-exposure to dampness, closed footwear for long periods and infection from shower rooms, swimming pools or manicure/pedicure salons. Persons who sweat profusely or work in humid moist conditions are more susceptible to nail fungal infections. It is also more common in those suffering diabetes, AIDS or circulation problems.

In most cases, the fungal infection of the nail is due to Trichophyton rubrum. Common mold causes include Neoscytalidium, Scopulariopsis, and Aspergillus. Infected nails appear brittle and lose luster. They might be discolored yellow. The nails might change in shape and loosen out of the bed. Nail fungal infections are treated with Fluconazole griseofulvin, terbinafine or itraconazole. Creams and ointments might be prescribed too. Those suffering fungal infection of the nail must maintain good foot hygiene and wear well-fitting footwear.