nail surface, is associated with a distal phalanx fracture, or the nail or its margins are disrupted, the presence of a significant nail bed injury should be suspected Nail trephination facilitates drainage with relief of pressure and pain Trephination is most effective within 24 to 48 hours (before clotting limits its success), but may be attempted in older subungual hematomas if significantly symptomatic In addition to pain control, the procedure also reduces risk of secondary infection This treatment alone suffices for uncomplicated subungual hematomas with intact nail margins, regardless of the size of the hematoma The trephined opening should be large enough (larger than to mm) to allow for ongoing drainage without risk of closure by a new clot Producing two openings in the nail may promote more complete drainage (see Chapters 109 Hand Trauma and 130 Procedures ) When the nail or its margins are disrupted and/or a displaced phalangeal fracture is present, the nail should be removed and the nail bed repaired and splinted While current data have failed to show improvement in fingertip injuries treated with antibiotics, they are often prescribed for patients with underlying fractures and those with severe soft tissue injuries Subungual Foreign Body Foreign bodies such as wood splinters or metallic shavings can become embedded under the nail and cause pain and/or infection When the foreign body is only partially embedded, the nail can be trimmed close to the nail bed, and the object’s projecting end grasped with splinter forceps and gently extracted If a portion remains or the foreign body is deeply embedded from the outset, a digital block should be performed The portion of the nail overlying the object can be shaved down with a scalpel until the foreign body is exposed and can be extracted Alternatively, the nail can be lifted and the object removed (see Chapter 130 Procedures ) After removal, the finger should be soaked in warm, soapy water, and an antibiotic ointment and protective dressing applied The finger should be soaked three times a day for to days In the unusual case of a child with multiple subungual splinters or fragments, it is best to remove the nail, clean out the foreign material, irrigate thoroughly, and then replace the nail (after trephining it to allow drainage) When there is concern for concurrent infection, antibiotic treatment should be provided Hair Tourniquet A hair tourniquet injury is unique to the pediatric population It involves strangulation of a digit (or genitalia) by a hair or fine thread Hair tourniquets are most common in young infants and can be the cause of unexplained irritability or crying In these cases, hair becomes unintentionally entwined around an infant’s