What Is A Splinter Hemorrhage

Splinter haemorrhage is when streaks of blood pool under the surface of the nail.¹ They appear as fine red or brown lines synonymous with splinters, hence their name. Splinter haemorrhages can arise from an array of medical conditions, some of which may have life-threatening complications; therefore, this article will discuss and primarily focus on the underlying causes of splinter haemorrhage, their presentations, early detection and treatment measures.

The structure of this article will be as follows:

• Understanding splinter haemorrhage 
• The causes of splinter haemorrhage 
• The signs and symptoms of splinter haemorrhage 
• Tests, investigations and diagnosis 
• Treatment and management
• Prevention 

Understanding splinter haemorrhage 

To deconstruct the meaning of splinter haemorrhage further and comprehend its meaning, we can look at the individual words. ‘Splinter’, as aforementioned, represents the streaking of blood underneath the nail. They can appear in a brown or reddish colour, similar to a thin wooden splinter.¹ ‘Haemorrhage’ means the leakage of blood from its vessels.² With regards to splinter haemorrhage specifically, the haemorrhage commonly occurs in the tiny blood vessels underneath the nail- the capillaries. 

Splinter haemorrhages can appear as single, or multiple streaks, distal to the cuticle of the nail (near the free edge of the nail). Although the most common location of splinter haemorrhage is near the free edge of the nail, they can also occur more proximally (for instance near the cuticle).¹ However, this is a sign of a more serious underlying cause which will be discussed later in the article. 

The causes of splinter haemorrhage 

The causes of splinter haemorrhage can be classified into three sections:³

• Trauma
• Inflammation/ autoimmune conditions
• Infection
• Medications

The most common cause of splinter haemorrhage is trauma. For instance, injury to the nail resulting in the weakening or damage of capillaries can cause the escape of blood under the nail resulting in splinter haemorrhages. 

Although splinter haemorrhage is most commonly caused by trauma, it can often indicate more severe systemic disease. These include tiny clots (micro-emboli), that can travel through blood vessels and become lodged, hence damaging them.⁴ 

Another systemic cause is an autoimmune condition, where the body’s immune system attacks itself. In vasculitis (inflammation of blood vessels), the capillary walls thicken and obstruct blood flow resulting in tissue damage.⁴

Rheumatological causes of splinter haemorrhages make up a significant proportion of their presentation. Rheumatology encompasses a range of disorders that share a common feature of inflammation in the bones, muscles and joints.⁵ Nail psoriasis is an autoimmune rheumatological condition in which structural changes to the nail occur, such as pitting or discolouration, it often occurs subsequent to a diagnosis of psoriasis.⁶ 

The most significant condition that healthcare professionals will attempt to rule out after a presentation of splinter haemorrhage, is bacterial endocarditis. This condition is where the inner lining of the heart (the endocardium) becomes infected by bacteria passing through the bloodstream and into the heart.⁷ Increased susceptibility to bacterial endocarditis can occur through congenital (conditions present at birth), genetic, environmental and iatrogenic (through medical intervention) causes. These causes include:⁷

• Prosthetic heart valves
• Congenital heart disease
• Hypertrophic cardiomyopathy (thickening of the heart chambers)
• Damaged heart valves (following infection or heart disease 
• Recurrent endocarditis

Bacterial endocarditis is a serious condition and can have life-threatening consequences if left untreated. Complications such as heart failure and stroke arise from the damage to the heart valves and disruption of blood flow, therefore it is critical to treat this condition as early as possible.⁷

Certain medications used in the treatment of cancer may have side effects that lead to splinter haemorrhages. 60 to 70% of patients taking these medications, such as sunitinib and sorafenib are found to have splinter haemorrhages.⁸

Signs and symptoms 

The initial symptoms of splinter haemorrhage are relative to their respective underlying causes. However, the general signs and symptoms of splinter haemorrhage are:¹ 

• Single or multiple longitudinal lines under the nail
• Can occur in one or more nails 
• They may be asymptomatic 
• They don’t ‘whiten’ when you press down on them (non-blanching)
• Can be tender/ painful
• The red lines move in the direction of nail growth
• Haemorrhages in the distal part of the nail are commonly a result of trauma
• Proximal haemorrhage may be a result of systemic disease

It is crucial to note that if you notice splinter haemorrhages as a result of trauma to the nail, there is usually no need to visit a healthcare professional unless you feel anxious or worried. However, if splinter haemorrhages occur for an unknown cause or if you have felt feverish, fatigued, had joint or muscle pain, or have spotted other abnormal symptoms, please contact your local healthcare provider so that they can uncover the cause of the splinter haemorrhages. 

Tests, investigations and diagnosis 

Following a history of splinter haemorrhage onset, your healthcare provider may do some bedside examinations to investigate specific causes. These physical exams pay special attention to the heart and the circulatory system (the cardiovascular exam), as well as taking a better look at your joints, including the hands and nails (musculoskeletal exam).⁹

Alongside these physical examinations, the healthcare professional may ask to take some blood samples. This is to look at any foreign pathogens that may be in the blood (blood cultures) and to analyse specific cells in the blood (FBC and ESR).⁹ 

If any abnormal signs are noticed on physical examination or on the blood tests, some further imaging investigations may be ordered. These include a chest x-ray, an ECG (used to look at heart rate and rhythm) and possibly an echocardiogram (to look at blood flow within the heart).⁹

In most cases, splinter haemorrhages can be diagnosed from observation, however, diagnosing the underlying condition causing them may require all three of these tests and investigations. Your healthcare provider will discuss with you what each of these tests involves in-depth and how to move forward with treatment options.

Treatment and management 

Similar to the signs and symptoms of splinter haemorrhage, the treatment options are underpinned by the cause of them. In other words, the treatment of splinter haemorrhages is targeted at their underlying cause. 

In the case of a traumatic occurrence of splinter haemorrhages, there is usually no treatment required as it should go away by itself as the nail grows.⁸ Aiding nail growth and hastening the removal of splinter haemorrhages (caused by trauma) can be supplemented by a nutritious diet, rich in vitamin B and zinc.¹⁰

In the case of bacterial endocarditis, the treatment protocol depends on the type of bacteria that has caused the infection, as well as if you have had any risk factors, specifically a prosthetic valve (i.e. recently having a valve replacement surgery). Commonly the treatment is with antibiotics, however, surgery may be indicated to fix or remove any damaged heart valves.¹¹

Treatment of vasculitis, nail psoriasis and other inflammatory causes of splinter haemorrhages are usually treated with a corticosteroid medication such as prednisolone.¹²

Prevention 

The prevention of splinter haemorrhages is again based on the original causes. For traumatic splinter haemorrhage, the only preventative measure would be to take caution with physical contact sports, or activities which could further damage capillaries in the nail bed. 

For infective causes such as bacterial endocarditis, practising good oral hygiene is a key component for the prevention of splinter haemorrhages as gum disease and abscesses can be a predisposition for bacterial endocarditis. Additionally, good hand hygiene is imperative to limit the spread of bacteria and the risk of infective endocarditis.¹³

Summary

In conclusion, a thorough understanding of splinter haemorrhages is essential for both healthcare professionals and individuals concerned about their health. These seemingly mild linear marks beneath the nails can be indicative of serious medical conditions as discussed.

The recognition of splinter haemorrhages and their significance is a crucial step towards early diagnosis and timely intervention. Through these steps, we can work towards the maintenance of not only our nails but more importantly our overall health, as well as improving and enhancing our quality of life.