Nail Trephination
Concern for phalanx fracture?
- Clean nail with povidone iodine or chlorhexidine
- Restrain extremity and digit
- Determine technique
- Note: If electrocautery is to be used, one should not clean the nail with isopropyl alcohol as it can ignite.
Contraindications to midazolam
- History of adverse event
- Current disease process causing myocardial depression
- Patients at risk for hypoventilation
X-ray Finger 3-view
Inclusion Criteria
- Subungual hematoma
Exclusion Criteria
- > 48 hours since onset/injury
- Nail fold disruption/laceration
- Intraarticular fractures
- Displaced/complex fractures
- Infected wound
Place splint
Patient to require anxiolysis?
Contraindications to midazolam?
Patient to benefit from peripheral nerve block?
Preform peripheral nerve block
Contraindications to nitrous oxide
- History of adverse event
- Vomiting
- Pregnancy
- Gas within body cavities (SBO, Pneumothorax, Otitis Media, etc)
Insulin syringe
- Place needle under distal edge of the nail (hyponychium)
- Advance proximally until hematoma drains
- Apply slight pressure to nail to aid in drainage
18 - 20 gauge needle
- Twirl the needle to bore into the hematoma until you see blood return
- Create hole big enough (3 - 4 mm) to ensure drainage
- Consider multiple holes if extensive drainage required
Things to avoid:
- Paper clip technique
- Unnecessary nail removal
Electrocautery or carbon laser
- Puncture nail with device in the center of the hematoma until you see blood return
- Create hole big enough (3 - 4 mm) to ensure drainage
- Consider multiple holes if extensive drainage required
Intranasal or Oral midazolam 20 min prior to procedure
Midazolam 10mg/mL intranasal solution
Midazolam suspension
Distal phalanx fracture?
Patient to soak in soapy water 3 times a day for 2 days
Cover with gauze dressing
Mesoscission
- Apply pads to patient's hand and test device
- Create several holes to ensure drainage
