Common Toenail Injuries in Athletes

Image 1. Demonstration of subungual hematoma trephination. Note the drop of blood after the procedure. Also note this is using a needle, its often easier with electrocautery.

Subungual Hematoma

Subungual hematomas are painful hematomas that occur under the toenail following trauma. Typically this trauma is acute such as stubbing a toe, but can also occur in endurance events as well. Around 1/3 of subungual hematomas will have associated nailbed lacerations or fractures. The exam is typically pretty straight forward and will reveal red-purple discoloration under the nail. During the evaluation, the key is to identify any fractures or lacerations as that can change management. Uncomplicated cases can be managed with nailbed trephination alone. Nail removal for large hematomas (>50% of nail surface area) to evaluate for lacerations is discussed in the literature but is considered controversial. Most athletes do very well and can return to play quickly if the hematoma is uncomplicated. The most common complications are poor nailbed cosmesis and onycholysis (removal of the nail plate from the nail bed).

Subungual Exostosis

Image 2. Clinical example of subungual exostosis.

Image 3. Foot radiograph showing bony projection at the great toe.

Subungual Exostosis is a benign osteocartilagenous tumor that occurs under toenails, most commonly the great toe. Although poorly understood, it is associated with repetitive microtrauma and can be seen in athletes. Exam will reveal a firm, fixed nodule with a hyperkeratotic smooth surface at the distal end of the nail plate. Radiographs will show a pedunculated radiopaque mass on the dorsomedial surface of the distal phalanx. Most cases are managed with surgical excision and athletes can return to play fairly quickly. Recurrence rate is about 4%, post-surgical deformity is about 16%.

Nailbed Laceration

Image 4. Example of a nailbed laceration after the nail is removed.

Image 5. Example of a nailbed laceration repair. Note the physician sutured the original nail plate back in place after.^[4]Mignemi, Megan E., Kenneth P. Unruh, and Donald H. Lee. “Controversies in the treatment of nail bed injuries.” Journal of Hand Surgery 38.7 (2013): 1427-1430.

Nailbed lacerations can involve the nail only or include the nailbed. About half the time they involve a fracture of the distal phalanx.. The lacerations are often obvious and can be easily correlated with a history of trauma. It is important to ensure that flexion and extension are intact and to obtain an XR to evaluate for fracture. Removal of the nail is not always necessary but should strongly be considered. The laceration should be repaired and the nail plate or artificial spacer should be sutured into the eponychial fold. In some cases, adhesive glue can be used. Antibiotics should be considered in some cases such as animal bites. In routine injuries, they do not seem to reduce the incidence of infection or osteomyelitis.

Ingrown Toenail

Image 6. Example of ingrown toenail with soft tissue infection of the affected side.

Image 7. Removal of part of the nail is a common treatment for ingrown toenail.

Ingrown toenails, technically termed onychocryptosis, is characterized by penetration of the periungual dermis by its contiguous nail plate often resulting in a cascade of foreign body, inflammatory, infectious, and reparative processes. The diagnosis is generally straightforward. Patients present with pain, swelling, edema, and erythema. Infection, including abscess, may or may not be present. In more chronic cases, there is marked nailfold hypertrophy. Treatment often involves excision of 20-25% of the nail under the lateral nailfold and then attempt to address underlying risk factors such as suitable footwear, onychomycosis, etc. Most athletes can continue to play if symptoms are mild to moderate. Following surgical excision, it may take 1-2 weeks of rest before a gradual return to play.

Onychodystrophy

Image 8. Example of mild onychodystrophy. Note the clinical presentation varies wildly based on the etiology.

Onychodystrophy refers to abnormal growth of the nail characterized by dystrophy (abnormal) and/or dyschromia (abnormal color). The etiology is broad and is often associated with other nailbed pathology, but may also suggest skin disease, neoplasms, systemic disease or drug reactions. Patients often report nail trimming problems, difficulty walking, discomfort in wearing shoes, pain, nail pressure and embarrassment. In most cases the treatment is directed at the underlying etiology with the goal of resuming normal nail growth and improving cosmesis.

Paronychia

Image 9. Example of acute paronychia.

Image 10. Example of acute paronychia.

Paronychia is inflammation, often infectious in origin, of the lateral and proximal nail folds. It can be acute (<6 weeks) or chronic (>6 weeks) and is more common in fingers than toes. Acute injuries are associated with tight fitting shoes and trauma while chronic paronychia are often the result of occupation related chemical irritants. In acute paronychias, patients report rapid onset of pain, swelling of the nail fold. On exam there may be erythema and edema and an abscess is often present. Management of acute paronychia includes topical antibiotics, topical burow’s solution or acetic acid, topical steroids and in severe cases, oral antibiotics. If an abscess is present it should be drained. Chronic paraonychia primarily involves discontinuing the offending activity, but may also involve topical therapies.

Onychomycosis

Image 11. Example of dermatophytoma, linear bands on the nail plate which are highly suggestive of onychomycosis.

Onychomycosis refers to a chronic fungal infection, most commonly affecting the great toe. The etiology is primarily tinea unguium, a dermatophyte, and less commonly non-dermatophytes and yeast. Patients will report white, yellow or brown discoloration of the nail. In addition to discoloration, the nail will frequently be thickened or detached from the nail bed. Dermatophytoma are linear, single or multiple white, yellow, orange or brown bands on the nail plate which are specific for onychomycosis. Treatment is topical antifungals in early superficial cases and oral antifungals in most cases. Terbinafine is the most effective oral agent.

– More Foot/Toe Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/foot/

References[+]

↑1	Simon RR, Wolgin M. Subungual hematoma: association with occult laceration requiring repair. Am J Emerg Med. 1987 Jul;5(4):302-4.
↑2	Meek S, White M. Subungual haematomas: is simple trephining enough? J Accid Emerg Med. 1998 Jul;15(4):269-71.
↑3	Case courtesy of Dr Ayush Goel, Radiopaedia.org, rID: 74749
↑4	Mignemi, Megan E., Kenneth P. Unruh, and Donald H. Lee. “Controversies in the treatment of nail bed injuries.” Journal of Hand Surgery 38.7 (2013): 1427-1430.
↑5	George A, Alexander R, Manju C. Management of Nail Bed Injuries Associated with Fingertip Injuries. Indian J Orthop. 2017;51(6):709-713. doi:10.4103/ortho.IJOrtho_231_16
↑6	Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg Eur Vol. 2016;41(4):423-430. doi:10.1177/1753193415601055
↑7	Elewski BE. Onychomycosis. Treatment, quality of life, and economic issues. Am J Clin Dermatol 2000;1:19-26.