Treating Acute Toenail Injuries In Athletes

Kristine Hoffman DPM

Acute toenail injuries in athletes are a relatively common occurrence. These injuries can result from repetitive microtrauma, such as the nail plate contacting the end of the shoe during a long-distance running race, or a single traumatic event such as a crush injury from a player’s foot getting stepped on. Acute nail injuries can cause significant pain and temporary limitation of activities. Long-term complications of these nail injuries include secondary fungal infections and nail plate deformities.

Subungual hematoma. Repetitive trauma to the nail plate as well as blunt and sharp traumatic injury can result in a collection of blood below the nail plate. Despite their size, these injuries can be extremely painful due to the pressure that develops below the nail. Pain can last for several hours to several days depending on the extent of fluid accumulation and the integrity of the nail folds.1 Subungual hematomas are common sport injuries, most frequently occurring in runners. They occur secondary to poor shoe fit, steep and irregular terrain and lower extremity edema.

Small, non-painful subungual hematomas that involve less than 25 percent of the nail do not require any treatment. With these small lesions, fluid will accumulate in the surrounding soft tissues and discoloration will gradually grow out to the free end of the nail plate. In painful lesions that involve more than 25 percent of the nail, authors have recommended trephination or avulsion, and evacuation of the subungual hematoma.1 There are numerous modalities for trephination, including handheld cautery, 18-gauge needle, nail drill, trephine, dental burr, heated paper clip, small rotary burr, #11 blade or carbon dioxide laser.2

Nail plate avulsion is another modality for the evacuation and treatment of subungual hematoma. Avulsion allows inspection and repair of concomitant nail bed lacerations. Recommendations vary as to the extent of nail plate involvement that warrants nail avulsion over trephination.

Malay reports that structurally stable nail folds and involvement of less than 25 percent of the nail pate should receive trephination.1 Simon and Wolgin report a 60 percent incidence of nail bed laceration requiring nail plate avulsion and repair in subungual hematomas involving more than 50 percent of the nail.3 They reported a 94 percent incidence of nail bed laceration requiring nail plate avulsion and repair regardless of hematoma size when distal phalangeal fracture was present.3 Van Beek and colleagues recommend avulsion in cases involving 25 to 50 percent of the nail plate due to a 50 percent incidence of associated nail bed laceration.4 More recent studies have shown that trephination is a viable treatment option regardless of hematoma size or the presence of distal phalanx fracture.5

Possible complications resulting from subungual hematoma include nail plate deformity and secondary infection. Both significant force and a large fluid accumulation can result in separation of the nail plate from the nail bed, leading to traumatic onycholysis. Traumatic injury to the germinal nail matrix can result in permanent nail deformity. Separation of the seal of the nail cuticle exposes the nail bed to both bacterial and fungus, leading to potential secondary infection.

Nail bed laceration. Significant sharp or blunt trauma to the digit can result in laceration of the nail bed. These injuries are frequent in team sports such as soccer and football in which a cleat-wearing player may forcefully step on the digit of another player. Additionally, these injuries occur in kicking sports in which a missed kick may lead to the digit contacting a non-mobile object. Nail bed lacerations are reportedly present in 60 percent of hematomas involving 50 percent or more of the nail and in 94 percent of distal phalanx fractures.3,4

The recommended treatment for nail bed laceration involves nail plate avulsion, irrigation, debridement and primary repair. Following a local anesthetic digital block, avulse the affected nail plate. Then prepare the digit with iodine or another antiseptic solution, apply a sterile draping, exsanguinate the digit and apply a digital tourniquet. Irrigate the nail bed and remove debris and remaining hematoma. Take care to avoid aggressive debridement as the nail bed tissue is friable and easily disrupted, which can lead to scar tissue formation. One should repair nail bed lacerations using 4-0 to 5-0 absorbable sutures on a tapered needle. Soft tissue adhesives, such as Dermabond (Ethicon), are an alternative to suture closure.6 One should insert either the nail plate or non-adherent gauze between the proximal nail bed and proximal nail fold to preserve the proximal nail groove. Then apply standard sterile dressings.

Possible complications of nail bed lacerations include hypertrophic scar formation that inhibits proper adhesion of the nail plate to the nail bed and damage to the germinative matrix resulting in absent or irregular nail growth and infection.1 Nail plate laceration with a digital fracture constitutes an open fracture and necessitates appropriate antibiotic management. Fox reports a case of osteomyelitis following an open nail bed injury and recommends irrigation, debridement and parental antibiotics in these injuries to decrease the risk of secondary osteomyelitis.7

Acute paronychia. Paronychia is an inflammatory condition of the epidermis bordering the nail that most commonly results from infection but may also have a non-infectious etiology, such as an ingrown nail, contact irritants, foreign bodies and prolonged exposure to moisture. Paronychia is a common injury in athletes due to tight fitting shoe gear, trauma and prolonged exposure to moist environments. Acute paronychia typically presents with redness, swelling, pain and possible fluctuance or purulent drainage from the paronychium. The most common infecting organisms are Staphylococcus aureus, followed by streptococci and Pseudomonas.8

Several treatment modalities for paronychia exist and treatment choice depends on the severity of the disorder. Warm water soaks three to four times per day, topical antibiotics and topical antibiotics in combination with topical corticosteroids are reportedly effective treatments for mild paronychia.8,9 More severe paronychia and treatment resistant lesions frequently require antibiotic therapy. If drainage is present, obtain cultures prior to initiating antibiotic therapy. The anti-staphylococcal agents clindamycin (Cleocin, Pfizer) and cephalexin (Keflex, Aspen Pharmacare) are in frequent use as initial empirical antibiotics. For athletes who participate in sports in which water and dirt contamination are frequent, consider broad-spectrum oral antibiotics such as amoxicillin/clavulanate (Augmentin, GlaxoSmithKline), clindamycin and trimethoprim/sulfamethoxazole (Bactrim, Roche) in the treatment of paronychia.10

Surgical treatment of paronychia is recommended for severe lesions and when an abscess is present. Surgical management begins with a local anesthetic block of the digit and preparation with a topical antiseptic. Then remove a 2 to 3 mm linear portion of the nail margin, which relieves the cutting effect of the edematous nail fold and allows sustained drainage and rapid relief.11 For athletes, due to the potential side effects of systemic antibiotics as well as the desire for a rapid return to activity, surgical treatment is frequently the optimal treatment modality.

Progressive infection is a possible complication of paronychia. Subungual abscess with elevation and disruption of the nail plate may occur.10 In rare cases, paronychia reportedly progresses to osteomyelitis of the underlying distal phalanx.12

In Conclusion

Acute toenail injuries are a common occurrence in many sports including running, soccer and football. Prompt diagnosis and management can lead to improved outcomes with the prevention of complications and more rapid return to sport.

1. Malay DS. How to address nail bed injuries. Pod Today. 2006;19(1):38-46.

2. Helms A, Brodell RT. Surgical pearl: prompt treatment of subungual hematoma by decompression. J Am Acad Dermatol. 2000;42(3):508-509.

3. Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. 1987;5(4):302-4.

4. Van Beek AL, Kassan MA, Adson MH, Dale V. Management of acute fingernail injuries. Hand Clin. 1990;6(1):23-35.

5. Batrick N, Hashemi K, Freij R, Mackway-Jones K. Treatment of uncomplicated subungual hematoma. Emerg Med J. 2003;20(1):65.

6. Strauss EJ, Weil WM, Jordan C, Paksima N. A prospective, randomized controlled trial of 2-octylcyanoacrylate versus suture repair for nail bed injuries. J Hand Surg Am. 2008;33(2):250-3.

7. Fox IM. Osteomyelitis of the distal phalanx following trauma to the nail: A case report. J Am Podiatr Med Assoc. 1992;82(10):542-544.

8. Hochman LG. Paronychia: more than just an abscess. Int J Dermatol. 1995;34(6):38595;

9. Wollina U. Acute paronychia: comparative treatment with topical antibiotic alone or in combination with corticosteroid. J Eur Acad Dermatol Venereol. 2001;15(1):82-84.

10. Rigopoulos D, Larios G, Gregoriou S. Acute and chronic paronychia. Am Fam Physic. 2008;77(3):339-346.

11. Keyser JJ, Littler JW, Eaton RG. Surgical treatment of infections and lesions of the perionychium. Hand Clin. 1990;6(1):137-153.

12. Brook I. Aerobic and anaerobic microbiology of paronychia. Ann Emerg Med. 1990;19(9):994-996.

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