#2 Nail Trephination – part 2

Revisiting the finger flambe blog post made me remember the very first experience I had, as a patient myself, with nail trephination.  I had nearly forgotten about this experience.

I was a second-year student at the University of Virginia where I took the pre-med curricula and hoped to go to medical school.  During one of the winter breaks, I injured my big toe while skiing. I was just a beginner skier and I recall the tremendous amount of stain and trauma through the toes and feet while wearing ski boots.  It is also possible that my rental boots did not fit me correctly.  In any case, I developed some painful combination of subungual hematoma and paronychia. I did not understand the pathophysiology anyway but I knew it hurt like hell and I was limping. It looked a bit like this:

A subungual hematoma is a collection of blood under the finger nail that can cause tremendous pain and become infected.  The treatment is to release the blood by making a hole in the nail, called trephination.

I went to the Student Health Building which at that time was near the old Medical School Building, across from the Corner. The doctor who saw me was very kind and told me had to do one thing to me to release the blood and pus that was trapped beneath the toenail.  He took a large paper clip and unbent it like so:

Then he went to the side counter of the exam room and connected a Bunsen Burner to a gas source. He lit the Bunsen Burner and placed the end of the paper clip into the heat of the flame until it was golden hot.

Then he touched the red hot part to my toenail which burned a hole in the nail and allowed all the nasty stuff in there to flow out. Wow! Whoever said going to Student Health was boring?

What I learned many years later, was that it is possible to take a very sharp needle like an 18 gauge or a 16 gauge needle used for venipuncture and drawing blood to trephinate a nail.  Using gentle pressure and rotating the very sharp point, one can very gently make a hole in the nail without flames and drama

This was the technique I used and taught to students and residents for many years. Just apply gentle pressure with a very sharp, sterile needle. Ease it back and forth through the nail until you release the fluid underneath. No flames or fire alarms needed and it gets the job done.