Diagnosis: Subungual hematoma
A 35-year-old male presented with a black discoloration under the great toenail following a marathon. The patient reported pain and throbbing in the affected toe, prompting evaluation. Examination revealed a subungual mass consistent with a hematoma, raising the need for appropriate management to alleviate symptoms and prevent complications.
A 35-year-old male marathon runner presented with a 3-day history of a dark, painful discoloration under his left great toenail following a marathon. He described the pain as throbbing and worsening with pressure. On examination, the toenail was intact but exhibited a significant subungual hematoma.Color: Dark red to black discoloration under the nail.Size: Hematoma occupying more than 50% of the nail bed.Location: Subungual area beneath the left great toenail.Pressure: Tenderness upon palpation, with no signs of infection.Mobility: Nail plate appeared stable without signs of detachment.
The patient reported that the discoloration began suddenly after completing a marathon, with no prior history of trauma to the toe. He had previously experienced minor nail trauma but had not sought treatment. He denied any significant past medical history, family history of bleeding disorders, or use of anticoagulants. He is an active runner and has participated in multiple marathons without prior incidents.Onset: Sudden discoloration after marathon running.Triggers: Intense physical activity and prolonged pressure on the toe.Prior treatments: None reported for this incident.Past medical history: No significant medical issues.Social history: Non-smoker, no alcohol use, active in sports.
Acute / First-Line ManagementDrainage: If the hematoma is larger than 50% of the nail bed and symptomatic, consider needle drainage or trephination using a heated instrument or a cautery device to relieve pressure.Pain management: NSAIDs such as ibuprofen 400-600 mg orally every 6-8 hours as needed for pain control.Wound care: Clean the area with antiseptic and cover with a sterile dressing post-drainage.Workup and Diagnostic ConfirmationClinical evaluation: Diagnosis is primarily clinical based on history and examination findings.X-ray: Consider if there is suspicion of underlying fracture or significant bony injury.Follow-up: Monitor for signs of infection or complications in the following days.Long-Term ManagementNail care: Advise on proper trimming and care of the toenails to prevent future injuries.Footwear: Recommend proper fitting shoes and possible use of protective toe caps during high-impact activities.Reassess: Schedule follow-up in 1-2 weeks to evaluate the healing process and nail integrity.
Onychomycosis: Fungal infection of the nail can cause discoloration but usually presents with thickening and debris under the nail.Subungual melanoma: Rare but serious; presents as a dark streak or discoloration without trauma history.Traumatic nail avulsion: Significant trauma may lead to hematoma but typically involves nail loss or detachment.Psoriasis: Can cause nail pitting and discoloration but would also show skin lesions or a family history.Hemangioma: Vascular lesion that can cause nail bed discoloration; typically more raised and soft to palpation.Dermatophyte infection: Can cause discoloration but usually presents with scaling and itchiness.Paronychia: Infection of the nail fold that may cause redness and swelling but not typically a hematoma.Systemic conditions: Conditions like vasculitis can cause nail changes but would have systemic symptoms.
High-Yield PearlsDiagnosis: Subungual hematomas are common in athletes and typically occur after trauma; history and physical examination are crucial for diagnosis.Management: Pain relief and drainage of the hematoma are critical to prevent pressure necrosis of the nail bed.Prevention: Proper footwear and nail care are essential in preventing recurrent injuries in athletes.Complications: Monitor for infection and nail loss, which may necessitate further intervention.Education: Educate patients on recognizing signs of complications and the importance of timely treatment.Timely drainage of a subungual hematoma can prevent complications and ensure proper nail regrowth.
Tags: subungual hematoma, runner