Subungual Hematoma Treatment 2026: Trephination Guide | DPM

Quick answer:A subungual hematoma is blood trapped under the nail after an injury. When pain is severe, a podiatrist can relieve it with trephination — a tiny hole to drain the blood. The nail may loosen or fall off and regrows over several months, and a significant injury should be checked for a fracture. Call (810) 206-1402.

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Township, MI. Last updated April 2026.

A subungual hematoma — bleeding beneath the nail plate from direct trauma, repetitive microtrauma from running, or crushing injury — is one of the most painful acute nail conditions encountered in podiatric practice. Appropriate management depends on hematoma size, time elapsed since injury, and whether nail plate disruption warrants exploration for underlying nail bed laceration.

Mechanisms of Injury

Acute subungual hematoma results from direct impact (dropping a heavy object, kicking a fixed object) that ruptures the subungual blood vessels between the distal phalanx and the nail plate. Repetitive microtrauma hematoma — “runner’s toe” or “black toenail” — accumulates gradually from the nail plate impacting the toe box with each footstrike, particularly in shoes with inadequate toe box depth or during prolonged downhill running that drives the toes forward. The great toenail and second toenail are most commonly affected.

When to Trephinate

Trephination (decompression of the hematoma by creating a small hole through the nail plate) is indicated when: hematoma covers more than 25–50% of the nail plate area, pain is severe, and presentation is within 48 hours of acute injury before clot organization. The procedure uses a heated wire (electrocautery), rotary drill, or 18-gauge needle to create a small opening through the nail plate over the hematoma — releasing the accumulated blood and immediately relieving pressure and pain. Post-trephination care includes cleansing, protective dressing, and daily wound inspection for infection signs. Trephination is unnecessary for small hematomas (<25%) or those older than 48–72 hours, where observation and nail protection are appropriate.

Nail Plate Disruption and Nail Bed Laceration

Complete nail avulsion at the time of injury requires exploration of the nail bed for laceration — particularly for injuries with hematoma involving more than 50% of the nail area, which has a high correlation with underlying nail bed laceration. Nail bed lacerations are repaired with 6-0 absorbable suture to restore the smooth nail bed surface that guides normal nail regrowth. The original nail plate is replaced as a biological splint over the repair or a non-adherent nonadherent dressing is used if the original plate is damaged beyond reuse.

Nail Regrowth and Prognosis

Toenail regrowth following complete nail loss proceeds at approximately 1–1.5mm per month from the nail matrix — requiring 12–18 months for complete great toenail regrowth. Patients should expect nail plate dystrophy (ridging, thickening, color change) in the new nail during the regrowth period. Permanent nail dystrophy results from nail matrix damage — a risk with severe crush injuries, deep lacerations involving the matrix, or repeated trauma to the same nail. Protective nail splints and wider toe box footwear during regrowth prevent repeated microtrauma during the vulnerable period.

Nail Injury Care at Balance Foot & Ankle

Dr. Biernacki at Balance Foot & Ankle provides trephination, nail bed laceration repair, and nail avulsion procedures with same-day appointments for acute nail injuries. Evaluation and management of runner’s toe and chronic nail microtrauma from footwear fit issues are also available. Call (810) 206-1402 for a same-week or urgent nail injury evaluation.

Visit Balance Foot & Ankle — Same-Day Appointments Available

Our podiatry team serves patients throughout Michigan including Howell, Brighton, and Bloomfield Township. If you’re dealing with heel pain, ingrown toenails, or a foot injury, we have same-day appointment availability.

Frequently Asked Questions

How long does it take a toenail to grow back?

6-12 months for a full big toenail. Smaller toenails 4-6 months. Speed varies with age, circulation, and nutrition.

Will this affect other nails?

Trauma affects only the injured nail. Fungal infection can spread without treatment. Systemic causes affect multiple nails simultaneously.

Should I cover the nail or leave it open?

Cover with a breathable bandage during work or activity. Leave open at night for healing. Keep dry and clean.