• Subungual hematoma with pain.

• Some experts suggest that nail removal and repair should be prompted by the percentage of nailbed involved (eg, greater than 25–50%), but this is not supported in the literature.

• Procedure is limited to simple hematomas, not complex crush injuries with associated fractures or nailbed injuries.

• Immunosuppression.

• Do not trephinate artificial acrylic nails using cautery (flammable).

• Do not prepare the nail with alcohol (also flammable).

• 10% povidone-iodine (or equivalent).

• Sterile gloves and gauze.

• Single-use, disposable electrocautery device (sterile) is preferred.

• A needle or metal paperclip heated in a flame is an alternative to electrocautery. A metal paperclip is preferred because it is blunt and will do less damage if inserted too far.

• Another alternative is to use either an #11 blade or 18- or 20-gauge needle in a twisting motion to drill the nail.

• Infection (very rare).

• Pain (if done correctly, procedure should provide pain relief).

• Nail deformity (rare, and associated with more complex injuries).

• Immobilization is important for young children; movement during the procedure can lead to injury to the nailbed or fingertip.

• Hide the cautery device from view of the young child until just before the procedure. Explain the procedure to older children, emphasizing that holding still will prevent pain.

• Do not mistake the pain of an underlying fractured phalanx for the pain of a hematoma.

• Obtain a radiograph if indicated by history or examination.

• Consider nail removal or specialist consultation for management and follow-up when any of the following is present:

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  • The nail or nailbed is disrupted.

  
  

  • There is a displaced fracture of the phalanx.

  
  

  • There is substantial periungual blood (suggesting eponychial injury).