Nail Trephination



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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