Subungual hematomas frequently occur in distance runners and I tend to see a lot of them in my practice. While it can be a controversial topic in regard to either draining or removing the entire nail, I learned early in my career that it is best to remove the entire nail.
The important concept to remember is there is an injury under the nail plate that needs to heal. The nail bed is either lacerated or ulcerated, which produces the bleeding. With runners, there is typically repetitive microtrauma that creates the bleeding to the nail bed and this is usually from an ulcer. Piercing the nail plate and draining the bleeding is an option if one does it early enough. However, continued bleeding can still occur and the area can fill back up within 24 hours, producing more pain.
Another important concept to consider is the nail bed is compromised and will heal better without the irritation from the nail plate. There is really no reason to leave the nail plate intact. Even when considering a simple draining of the hematoma, one should consider local anesthesia for the digit in order to allow for ample pressure to puncture the nail so nail plate removal will cause no further pain.
The nail bed typically will only remain tender for a day or two. Then it is epithelial tissue and becomes dry. I allow runners to run within 24 hours after removal of the nail and have not had any issues with pain or healing. It is without a doubt safer to remove the nail, especially if the patient is going to resume running. Continuing to run with a loose toenail and increased pressure is akin to running with a foreign body in the shoe, creating even more irritation and possibly infection.
I have cases in which I have removed the nail on runners a few days before a marathon and patients were very happy and able to run comfortably. My approach is using a standard digital block with a bupivacaine (Marcaine) and lidocaine mixture (Lidoderm, Endo Pharmaceuticals). Free the nail plate and avulse it in its entirety, regardless of how much of the plate is involved in the trauma. Leaving any nail could still result in irritation or spicules that could produce pain during running.
In regard to postoperative care, I employ a gauze wrap with Coban for 24 hours. Afterward, the patient will begin foot soaks (or aggressive cleaning with antibacterial soap) and use a dressing with a topical ointment and a Band Aid. I advise patients that they can run within 24 hours if they would like, depending on their pain (which is usually minimal).
The photos depict a nail avulsion I performed on a runner who had just completed the Cincinnati Marathon and was hoping to run the Pittsburgh Marathon in five days. I performed a nail avulsion, reassuring him that he would be able run that weekend. He was able to run and provided these photos.
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