Splinter Hemorrhage Causes and Treatment | GetWellGo

What causes splinter hemorrhages in fingernails?

Splinter hemorrhages are red-to-brown, linear, small streaks underneath the nails that have a splinter-like appearance. They result from small blood clots injuring the minute capillaries beneath the nails. 

Splinter Hemorrhages Causes

Infective Endocarditis (Most Classic Association)

• Bacterial heart valve infection.
• Emboli from the infection damage nail bed capillaries.

Trauma

• Most frequent general cause (e.g., nail picking, sports trauma).
• Frequently asymptomatic and occurs in individuals with heavy hand use.

Systemic Diseases

• Vasculitis (blood vessel inflammation)
• Psoriasis
• Systemic lupus erythematosus (SLE)
• Rheumatoid arthritis

Other Medical Conditions

• Chronic renal failure
• Antiphospholipid syndrome
• Scurvy (Vitamin C deficiency)
• Disseminated intravascular coagulation (DIC)

Medications and Drug Use

• Anticoagulants (e.g., warfarin, heparin)
• Chemotherapy
• Chronic corticosteroid use
• Illicit drug use (particularly IV drug use associated with endocarditis)

Normal Finding

• In a few instances, they can be idiopathic (no identifiable cause) or in healthy people, particularly with minor unrecognized trauma.

Splinter Hemorrhage Diagnosis

Diagnosis of splinter hemorrhages is by clinical examination, history, and investigations to uncover the cause. A systematic approach follows:

Clinical Examination

• Search for linear red/brown discoloration under nails, running parallel to nail growth.
• Typically visible in distal nail bed.
• Examine for more than one fingernail being involved.
• Check whether painful or painless.
• Search for evidence of systemic illness (e.g., fever, weight loss, heart murmur).

Detailed History

• History of trauma: Recent hand injury, nail-biting, manual labor
• Infective signs: Fever, chills, recent infection
• Cardiac history: Known valve disease, prosthetic valves, IV drug use
• Autoimmune history: Joint pain, rashes, oral ulcers
• Medication history: Anticoagulants, immunosuppressants

Investigations (If systemic cause suspected)

a. Laboratory Tests

• Blood cultures: If infective endocarditis suspected.
• Complete blood count (CBC): Anemia, leukocytosis.
• ESR/CRP: Inflammatory markers.
• Rheumatoid factor, ANA, ANCA: For autoimmune diseases.
• Coagulation profile: If bleeding tendency suspected.

b. Cardiac Evaluation

• Echocardiography (particularly Transesophageal Echo - TEE): For the identification of vegetations or valve abnormalities (particularly in infective endocarditis).
• Electrocardiogram (ECG): For evaluation of heart rhythm and other cardiac signs.

c. Other Relevant Tests

• Urinalysis: Hematuria/proteinuria (in vasculitis or infective endocarditis).
• Skin biopsy (seldom required): If vasculitis suspected and other signs.

Differential Diagnosis

• Trauma – typically single nail, recent trauma.
• Infective endocarditis – multiple nails, systemic illness.
• Autoimmune disease – associated with joint pain, skin rash.
• Psoriasis – be aware of pitting, onycholysis.

Nail Splinter Hemorrhage Treatment

Treatment varies based on the etiology, since splinter hemorrhages per se are not treated. A breakdown of causes is as follows:

Traumatic Splinter Hemorrhages

• Most common type.
• Nothing specific to be treated.
• Reassurance and observation.
• Avoid additional trauma (e.g., nail biting, rough manicures).
• Will spontaneously resolve in 2–4 weeks as the nail grows.

Infective Endocarditis (IE)

• Needs immediate treatment.
• Hospitalization and IV antibiotics depending on sensitivity of culture.
• Echocardiography to determine vegetations.
• In rare instances, surgical repair or replacement of the valve may be required.

Autoimmune Disorders (e.g., SLE, Rheumatoid Arthritis, Vasculitis)

• Manage the underlying inflammatory disease.
• Steroids, immunosuppressants, or DMARDs as needed.
• Systemic disease control and regular monitoring prevent recurrence.

Drug-induced

• If anticoagulants (e.g., warfarin, heparin) are the etiology:
• Re-evaluate and reduce dose if bleeding is significant.
• INR monitoring with warfarin.
• Consult prescribing doctor.

Nutritional Deficiencies (e.g., Scurvy)

• Vitamin C supplementation.
• Correct diet and reverse the deficiency.

Symptoms of Splinter Hemorrhage

Splinter hemorrhages are most often a sign, and not a disease in and of themselves. They do have a variety of associated symptoms based on cause.

Visible Nail Signs

• Thin, vertical brown or red streaks beneath the nail plate.
• Look like a wood splinter, so named.
• Typically oriented parallel to nail growth.
• Can be present on one or more nails.

Systemic Symptoms:

• Fever or chills
• Fatigue or malaise
• Shortness of breath
• Heart murmur
• Weight loss
• Night sweats
• Joint pain or swelling
• Skin rashes
• Petechiae or other signs of bleeding

How to identify splinter hemorrhages?

Splinter hemorrhages are small, longitudinal bleeds beneath the toenails or fingernails. Below are steps to identify and distinguish them:

Step-by-Step Identification:

Check the Nails Closely

• Employ adequate light and, if possible, a magnifying lens.
• Examine the nail plate (the hard component) and look for:
• Slim, longitudinal red to brown-black streaks
• Vertical lines from the base to the tip
• Generally found in the distal third of the nail

Count the Involved Nails

• Trauma usually involves one or two nails.
• Multiple nails may be involved in systemic causes (such as endocarditis or autoimmune disease).

Check Symmetry

• Bilateral involvement can imply a systemic cause.
• Asymmetric involvement is more likely due to trauma.

Look for Associated Signs

In infective endocarditis:

• Seek Osler nodes, Janeway lesions, fever, murmurs.

In autoimmune disease:

• Seek rash, arthralgia, or oral ulcers.
• Inquire about trauma or tool use, nail biting, manicures.

Subungual Hemorrhage Treatment

Subungual hemorrhage is the name for blood that is trapped under the nail plate, typically as a result of trauma. It can be painful or not, and treatment is based on the severity, size, and symptoms.

Mild Cases (Small, Pain-Free, or Minor Trauma)

• Observation only
• The blood will eventually grow out with the nail over weeks to months.
• Control of pain: Over-the-counter NSAIDs (e.g., ibuprofen).
• Avoid repetitive trauma and keep the area clean.

Moderate to Severe Cases (Painful, Large Hematoma)

• Goal: Decrease Pressure (If Nail is Not Broken)

Nail trephination:

• Done by a healthcare professional.
• A small puncture is created in the nail (with a heated needle, COâ‚‚ laser, or sterile drill) to allow drainage and decrease pressure.
• Quick relief from pain and does not cause nail loss.

When to Do It

• Within 24–48 hours after injury.
• Nail must be intact (not broken or infected).

Do NOT Try Drainage If:

• There is a laceration, nail bed injury, or suspected fracture.
• Signs of infection (redness, swelling, pus, fever).
• The hematoma is greater than 48 hours in duration and no longer tender.

Post-Treatment Care

• Stay clean and dry.
• Apply antibiotic ointment if trephination performed.
• Watch for signs of infection.
• Avoid overuse of injured finger/toe.

When to Refer to a Doctor

• Hematoma covers >50% of the nail.
• Persistent pain despite drainage.
• Fracture or nail avulsion suspected.
• Signs of infection present (pus, heat, spreading redness).
• Hematoma due to non-traumatic cause (e.g., unexplained bleeding).

Splinter Hemorrhage under Fingernail

A splinter hemorrhage beneath a fingernail looks like a thin, lengthwise (vertical) red to brown or black line underneath the nail plate. It resembles a splinter, hence the name.

What It Looks Like

• Color: Red, brown, or black (darkening with age).
• Shape: Vertical, thin streak.
• Location: Beneath the nail (not on the surface).
• Direction: Parallel to nail growth.

Splinter Hemorrhages and Heart Disease

Splinter hemorrhages beneath the nails are a clinical pointer towards underlying cardiac disease, most notably infective endocarditis—a severe bacterial infection of the heart valves.

Why It Occurs?

In infective endocarditis, aggregates of bacteria and cell debris (known as septic emboli) may:

• Detach from the heart valves.
• Embark in the bloodstream.
• Occupy small blood vessels (including those beneath the nails).
• This results in minute capillary bleeding, causing splinter hemorrhages.

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Best doctor for Splinter Hemorrhages in India

• Dr. Siddharth Garekar, Artemis Hospital Gurgaon
• Dr. Ramanjit Singh, Medanta-The Medicity Gurgaon
• Dr. Sunil Sanghi, Fortis Memorial Research Institute Gurgaon
• Dr. Ajita Bagai Kakkar, Max Hospital Saket