Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.
Medically Reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist, Balance Foot & Ankle Specialists, Michigan. Last updated April 2026.
Subungual hematoma — blood collection beneath the toenail from direct trauma — ranges from a minor bruise requiring no intervention to a painful tense hematoma requiring immediate drainage. The decision to drain depends on the extent of the hematoma and the degree of pressure-related pain.
Trephination: When and How
Drainage (trephination) is indicated when the subungual hematoma is causing significant pressure-related pain regardless of size, though hematomas covering greater than 25% of the nail are more commonly symptomatic. Trephination technique: heated cautery wire or battery-powered electrocautery pen creates a small hole through the nail plate — the nail plate is avascular and painless to perforate. One or two 3–4mm holes allow blood evacuation and immediate pressure relief. The nail should not be removed solely for hematoma drainage when the nail plate is intact and adherent — nail removal adds discomfort without improving outcomes for isolated hematomas.
Nail Bed Laceration and Nail Removal
Historically, a subungual hematoma covering >50% was considered an indication for nail removal to inspect the nail bed. More recent prospective studies demonstrate that trephination alone produces equivalent outcomes to nail removal and nail bed repair for hematomas in the setting of an intact nail and no displaced phalanx fracture. Nail removal is indicated when: the nail is already loose or avulsed; there is a displaced fracture of the distal phalanx requiring reduction; or the nail border is disrupted suggesting a nail bed laceration requiring direct repair with 6-0 absorbable suture under digital block. Dr. Biernacki at Balance Foot & Ankle evaluates and treats acute toenail injuries including subungual hematoma, nail bed lacerations, and traumatic nail avulsions. Call (810) 206-1402 at our Bloomfield Hills or Howell office for same-day urgent foot care.
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Our board-certified podiatrists treat this condition at two convenient locations. Same-day appointments often available.
Comprehensive Nail Health Guide
The toenails are a window into your overall health. Changes in nail color, thickness, texture, or growth rate can signal local infection, systemic disease, or nutritional deficiency.
Common Nail Problems and Their Causes
- Thickened nails: Usually fungal infection (onychomycosis), but also trauma or psoriasis
- Yellow/brown nails: Fungal infection most common; also smoking, nail polish staining
- Vertical ridges: Normal aging; also low iron, B12 deficiency
- Horizontal ridges (Beau’s lines): Indicate systemic illness or nail trauma
- White spots: Usually minor trauma; less commonly zinc deficiency
- Spoon-shaped nails (koilonychia): Iron deficiency anemia
- Clubbing: Requires evaluation for heart or lung disease
Learn more about toenail fungus treatment and ingrown toenail treatment at Balance Foot & Ankle.
Related Conditions & Resources
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Board-certified podiatrists Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients daily at our Howell and Bloomfield Township, MI offices.
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Toenail Injury Treatment in Michigan
A subungual hematoma (blood under the toenail) needs proper evaluation and treatment to prevent infection and permanent nail damage. Our podiatrists provide expert nail care.
Learn About Our Toenail Treatments → | Book Your Appointment | Call (810) 206-1402
Clinical References
- Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am. 2019;24(6):1166-1170.
- Meek S, White M. Subungual haematomas: is simple trephining enough? J Accid Emerg Med. 2000;17(5):368-369.
- Wang QC, Johnson BA. Fingertip injuries. Am Fam Physician. 2001;63(10):1961-1966.
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Howell, MI 48843
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
- Hallux Valgus (Bunions): Evaluation and Management (PubMed)
- Bunions (Mayo Clinic)