A heavy object falling onto a toenail causes immediate, intense, and throbbing pain due to a severe crush injury. This trauma frequently results in a subungual hematoma, which is blood trapped between the nail plate and the sensitive nail bed. The pressure from this pooled blood causes the characteristic throbbing sensation and discoloration, often appearing black or deep purple. Understanding the proper immediate and long-term care for this common injury helps manage pain and prevent complications.
Immediate First Aid Steps
The immediate goal after a crush injury is to control swelling, manage pain, and prevent infection. The RICE protocol—Rest, Ice, Compression, and Elevation—provides a structured approach to initial care. Rest the foot immediately, avoiding placing weight on the injured toe for at least the first 24 to 48 hours to prevent further damage.
Applying cold helps reduce blood flow, limiting swelling and providing a numbing effect for pain relief. Wrap an ice pack or frozen vegetables in a thin towel and apply it to the toe for about 20 minutes, repeating every one to two hours during the first day. Elevating the injured foot above the level of your heart, such as by propping it up with pillows, uses gravity to minimize swelling and throbbing pain.
To manage discomfort, over-the-counter pain relievers like acetaminophen or ibuprofen are effective. If the injury includes any breaks in the skin, clean them immediately to avoid infection. Gently wash the area for five minutes with mild soap and water, then apply an antibiotic ointment and cover it with a clean bandage.
Recognizing Signs of Severe Injury
While many crush injuries can be managed at home, certain signs indicate the need for professional medical attention. Seek prompt care if you notice any obvious deformity in the toe, which could suggest a bone fracture or joint dislocation. Also seek evaluation if you cannot move the toe normally or bear weight on the foot without severe pain.
Other serious indicators include a deep laceration that may require stitches, or if the nail plate is completely torn off or hanging loosely from the nail bed (nail avulsion). Signs of potential nerve damage, such as persistent numbness or tingling, also warrant immediate medical consultation. If bleeding is profuse or does not stop after applying direct pressure for 10 minutes, seek care right away.
Treatment Options for Subungual Hematoma
If the subungual hematoma covers less than about 25% of the nail and the pain is mild, observation and continued at-home care are sufficient. For a large, painful hematoma, the pressure needs to be relieved to alleviate throbbing and prevent potential loss of the nail.
A medical professional can perform trephination, which involves carefully creating small holes through the nail plate to allow the trapped blood to drain. This is done using a sterile needle or specialized electrocautery device, and the relief from pressure is immediate. This drainage is often preferred over full nail removal, even for large hematomas, provided the nail folds are intact.
Do not attempt trephination at home using tools like a heated paper clip, as this carries a significant risk of introducing bacteria, causing infection, or damaging the sensitive nail bed. Once the procedure is done, the toe must be kept clean and dry to prevent contamination of the new opening. The nail may still eventually detach, but the procedure helps reduce immediate discomfort.
Long-Term Monitoring and Recovery
In the days and weeks following the injury, careful monitoring is needed for signs of a delayed infection. Watch for increasing redness, warmth, swelling, or the presence of pus draining from the injury site. A fever or red streaks extending away from the toe also require prompt medical attention.
If the nail plate was significantly damaged or separated from the nail bed, it will often detach completely within a few weeks. Once the old nail is gone, the exposed nail bed should be protected with a clean, non-stick dressing until it hardens and new growth begins.
Toenail regrowth is a notoriously slow process, proceeding at an average of about 1 to 1.6 millimeters per month. A complete toenail can take anywhere from 12 to 18 months to fully regrow and reach the tip of the toe. Patience is required during this long process, and if the nail matrix—the growth center—was damaged, the new nail may have an altered texture or shape. Protecting the toe from further trauma during this recovery period is important.