Table 46 Causes of splinter haemorrhages

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Amyloidosis

Antiphospholipid syndrome Arterial emboli

Arthritis (notably rheumatoid arthritis and rheumatic fever) Behçet's syndrome

Blood dyscrasias (severe anaemia, high-altitude purpura)

Buerger's disease

Cirrhosis

Collagen vascular disease Cryoglobulinemia (with purpura) Darier's disease

Drug reactions (especially tetracyclines) Eczema

Haemochromatosis Haemodialysis and peritoneal dialysis

Heart disease (notably uncomplicated mitral stenosis and subacute bacterial endocarditis)

High-altitude living

Histiocytosis X

Hypertension

Hypoparathyroidism

Idiopathic (probably traumatic)—up to 20% of normal population

Indwelling brachial artery cannula

Malignant neoplasia

Occupational hazards

Onychomatricoma

Onychomycosis

Palmoplantar keratoderma

Peptic ulcer

Pityriasis rubra pilaris

Psoriasis

Pterygium

Pulmonary disease

Radial artery puncture

Raynaud's disease

Renal disease

Sarcoidosis

Scurvy

Septicaemia

Severe illness

Thyrotoxicosis

Minor and repeated trauma

Trichinosis

Vasculitis

Haematomas

Small haemorrhages originating in the nail bed remain subungual as growth progresses distally. The deeper layers of the nail are stained by small pockets of dried blood entrapped in the nail plate. Those produced by trauma to the more proximal part of the matrix will appear in the upper layers of the plate. Sometimes patches of leukonychia overlie the haematoma. Moderate trauma to the nail area, or blood dyscrasias, affecting extensive numbers of dermal ridges, determine whether the haemorrhages are punctate or result in large ecchymoses. Acute subungual haematomas are usually obvious, occurring shortly after trauma involving finger or toe nails. The blood which accumulates beneath the nail plate produces pain which may be severe. Haematomas are also discussed in Chapter 9.

Traumatic subngual toe nail haemorrhage may be entirely painless

The technique used for drainage depends on the size and site of the haematoma. Treatment is required to prevent both unnecessary delay in the regrowth of the nail plate and secondary dystrophy which might result from pressure on the matrix due to accumulated blood under the nail. In acute haematoma of the proximal nail area, drainage of the haematoma with a finepoint scalpel blade or by drilling a hole through the plate will give prompt relief from pain. Hot paper-clip cautery is a useful alternative to trephining the plate. This allows blood to be evacuated; the nail is then pressed against the bed by a moderately tight bandage, helping the nail plate to readhere. If this procedure is not immediately practicable, the pain can be relieved by elevating the limb and maintaining the position for approximately 30 minutes.

Occasionally subungual haematoma persists under the nail and does not migrate. A reddish-blue colour, irregular shape, and the absence of colour in the nail plate help to differentiate non-migrating subungual haematomas from naevi and other causes of nail pigmentation. It is advisable to remove the part overlying the subungual haematoma and identify and remove the dried blood in order to establish the diagnosis and to exclude more significant disease such as malignant melanoma.

In total haematoma, often observed when there is injury to the nail bed, the possibility of an underlying fracture must be considered: radiographic investigation is therefore necessary. The nail is removed, the haematoma evacuated and the wound repaired, if necessary with precise suturing of the nail bed using 6-0 polyglycolic acid or polydioxane sutures. The plate is then cleaned, shortened, narrowed and held in place by suturing to the lateral nail folds. The stitches are removed after 10 days, and usually the nail remains firmly attached.

The differential diagnosis of subungual blood from melanin may be difficult. The haemorrhage is between the nail plate and the matrix and nail bed epithelium, and is entrapped by the regrowing nail; the blood is not therefore degraded to haemosiderin by macrophages, and is not positive to Prussian blue staining. It can, however, easily be demonstrated: a small amount of the pigmented material is scraped from the nail plate undersurface and, collected in a test tube, a few drops of water are added and a reagent strip is dipped into it to test for the presense of haemoglobin. A positive test indicates the presence of blood.

Subungual bleeding may be due to many systemic conditions; Table 4.7 lists the most common morphological types.

Dorsal pterygium consists of a gradual extension of the proximal nail fold over the nail plate (Figures 4.30-4.32). The nail plate becomes fissured because of the fusion of the proximal

Table 4.7 Splinter haemorrhages and subungual haematoma in some

DORSAL AND VENTRAL PTERYGIUM

systemic conditions

Haematoma Splinters

Arterial lines/puncture Bacterial endocarditis Blood dyscrasia Cirrhosis

Collagen vascular disease + +

Cryoglobulinemia - +

Histiocytosis X (Langerhans cell histiocytosis) - +

Vasculitis - +

Figure 4.30

Post-traumatic pterygium (lateral longitudinal biopsy).

Figure 4.30

Post-traumatic pterygium (lateral longitudinal biopsy).

Splinter Haemorrhages

Figure 4.31

Pterygium at different stages in lichen planus.

Figure 4.31

Pterygium at different stages in lichen planus.

mm

Pterygium—terminal stage in lichen planus.

nail fold epidermis to the nail bed; its split portions progressively decrease in size as the pterygium widens. This often results in two small nail remnants if the pterygium process is central. Complete involvement of the matrix and nail bed in the pathological process leads to total loss of the nail plate, with permanent atrophy and scarring in the nail area (see

Pterygium is a wing-shaped scar and is always irreversible onychatrophy, page 35). Dorsal pterygium is particularly seen in scarring lichen planus; less often in peripheral ischaemia, severe bullous dermatoses, and radiotherapy on the hands of radiologists; it may follow injury; rarely, congenital forms occur.

Ventral pterygium, or pterygium inversum unguis (Figure 4.33), is a distal extension of the hyponychial tissue which anchors to the undersurface of the nail, thereby eliminating the distal groove. Scarring in the vicinity of the distal groove, causing it to be obliterated,

A text atlas of nail disorders 112 may produce secondary pterygium inversum unguis. Ventral pterygium may be seen in

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