When a heavy object strikes a toenail, the immediate, intense pain results from trauma to the underlying nail bed, often causing bleeding that becomes trapped beneath the rigid nail plate. This injury is known as a subungual hematoma, a collection of blood that puts pressure on the sensitive tissue below. The severity of this trauma dictates the necessary course of action, which ranges from simple at-home care to immediate professional medical intervention.
Essential Immediate Care
The first priority following the injury is to manage the swelling, pain, and internal bleeding that begin immediately after the impact. Applying cold therapy helps constrict small blood vessels, reducing internal bleeding and the formation of the subungual hematoma. Use an ice pack wrapped in a thin cloth for 10 to 20 minutes at a time, avoiding direct contact with the skin.
Keeping the injured foot elevated above the level of the heart uses gravity to limit blood flow, minimizing swelling and throbbing pain. This positioning should be maintained as much as possible for the first 48 hours following the injury. Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, can help manage acute pain and inflammation.
The toe must also be protected from further impact or friction. Immediately change into a roomy shoe or open-toed sandal. While a small hematoma often resolves on its own, continued pressure on the toe may worsen the pain. The goal of this initial management is to stabilize the injury.
Identifying When Professional Medical Attention is Needed
Certain signs indicate that the trauma is too severe for home treatment and requires immediate assessment by a healthcare provider. Severe, throbbing pain unrelieved by icing and elevation may signal a large subungual hematoma generating excessive pressure. Medical attention is recommended if the blood under the nail covers more than 25 to 50 percent of the nail surface.
Care is also necessary if there is suspicion of a fracture in the underlying toe bone, suggested by a visible deformity or the inability to bear weight on the foot. Urgent causes include deep lacerations, tears in the surrounding skin, or signs that the nail is significantly separated from the nail bed. These injuries may require specialized treatment like cleaning, stitching, or drainage to prevent complications.
The medical procedure for a large, painful hematoma is called trephination, where a small hole is created in the nail plate to drain the trapped blood and relieve the intense pressure. This quick intervention can provide immediate and substantial pain relief. A doctor will also evaluate the need for an X-ray to check for a fracture, a tetanus booster shot, or antibiotics, depending on the wound’s condition.
Long-Term Recovery and Nail Care
Once the initial injury is treated, the focus shifts to protecting the nail bed and managing the slow process of regrowth. The damaged nail will often eventually loosen and fall off, particularly if the trauma resulted in a large subungual hematoma that separated the nail from the nail bed. This common process protects the toe as the new nail forms underneath.
The exposed nail bed must be kept clean and protected to prevent infection until the tissue hardens, which typically takes seven to ten days. Cleaning the area gently with mild soap and water twice a day and covering it with a non-stick bandage is recommended. Monitor the area for signs of infection, such as increased redness, swelling, pus, or a fever.
Toenails grow at a very slow pace, and full regrowth after significant trauma can take a considerable amount of time, often ranging from 12 to 18 months. The new nail may initially appear slightly different in texture or shape. Continued protection of the toe from further injury is necessary throughout this long healing period to ensure the best cosmetic and functional outcome.