Nail bed injuries represent a high proportion of upper limb injury presentations to the emergency department. Overall the management of these injuries remains controversial, with a portion of nail bed injuries being over treated, which results in unnecessary procedures, healthcare costs, and patient morbidity. The traditional approach to subungal haematomas is nail plate removal, examination of the sterile matrix and a repair of the nail bed. There is some variation in the literature about treatment depending on the size of the subungual hematoma and if there is an associated fracture. Nail plate removal for simple injuries can result in unnecessary pain and a higher dressing burden for patients. Interestingly, nail trephination is suggested as the first line treatment for such injuries, and nail plate removal with repair should only be considered when there is a underlying distal phalanx fracture or the subungal haematoma covers more than 50% of the nail without a fracture. In addition to this, prophylactic antibiotics and splinting of tuft fractures remain topics of debate, both often being overused in the context of this injury, which can lead to higher complication rates without clear benefits.