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DISORDERS OF THE NAIL (HOOK NAIL, PINCER NAIL, SPLIT NAIL, OTHERS,…)

Can be viewed on www.diuchirurgiemain.org

Christian Dumontier, MD, PhD With the help of Dr Sylvie Carmès

Christian Dumontier, MD, PhD With the help of Dr Sylvie Carmès BSSH Instructional courses - series

BSSH Instructional courses - series 7

Christian Dumontier, MD, PhD With the help of Dr Sylvie Carmès BSSH Instructional courses - series
HOOK-NAIL DEFORMITY
HOOK-NAIL DEFORMITY
HOOK-NAIL DEFORMITY
HOOK-NAIL DEFORMITY
HOOK-NAIL DEFORMITY
HOOK-NAIL DEFORMITY
Shape of the nail
Shape of the nail
Shape of the nail The shape of the nail plate depends of: The bony support The
Shape of the nail The shape of the nail plate depends of: The bony support The
Shape of the nail The shape of the nail plate depends of: The bony support The
The bony support
The bony support
The volume of the pulp
The volume of the pulp
plate depends of: The bony support The volume of the pulp The orientation of the nail
plate depends of: The bony support The volume of the pulp The orientation of the nail
plate depends of: The bony support The volume of the pulp The orientation of the nail
Quality of the nail walls
Quality of the nail walls
Volar inclination of the nail is secondary to: Bone loss Pulp retraction/loss Treatment can only
Volar inclination of the nail is secondary to: Bone loss Pulp retraction/loss Treatment can only
Volar inclination of the nail is secondary to: Bone loss Pulp retraction/loss Treatment can only
Volar inclination of the nail is secondary to:
Bone loss
Pulp retraction/loss
Treatment can only be surgical
Possible surgical techniques
Possible surgical techniques
Possible surgical techniques Many techniques have been published With very few cases and short follow-up usually

Many techniques have been publishedPossible surgical techniques With very few cases and short follow-up usually ➡ Low level of evidence

surgical techniques Many techniques have been published With very few cases and short follow-up usually ➡
surgical techniques Many techniques have been published With very few cases and short follow-up usually ➡

With very few cases and short follow-up usuallyPossible surgical techniques Many techniques have been published ➡ Low level of evidence ! ?

Many techniques have been published With very few cases and short follow-up usually ➡ Low level
➡ Low level of evidence !
Low level of evidence !
?
?
Proposed techniques
Proposed techniques
Proposed techniques Supply with soft- tissue Bony support Retrocession flap (Dufourmentel) Excision of nail bed

Supply with soft- tissue

Proposed techniques Supply with soft- tissue Bony support Retrocession flap (Dufourmentel) Excision of nail bed
Bony support
Bony support
Proposed techniques Supply with soft- tissue Bony support Retrocession flap (Dufourmentel) Excision of nail bed

Retrocession flap (Dufourmentel) Excision of nail bed (Kumar) Hetero-digital flap (Atasoy)

of nail bed (Kumar) Hetero-digital flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the
of nail bed (Kumar) Hetero-digital flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the
of nail bed (Kumar) Hetero-digital flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the
of nail bed (Kumar) Hetero-digital flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the
of nail bed (Kumar) Hetero-digital flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the
of nail bed (Kumar) Hetero-digital flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the

Island flap (Gilbert, Tubiana)

flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the toe (Buback) Microvascular
flap (Atasoy) Island flap (Gilbert, Tubiana) Composite graft from the toe (Buback) Microvascular

Composite graft from the toe (Buback) Microvascular transfer (Morrison)

from the toe (Buback) Microvascular transfer (Morrison) Free bone graft (Tubiana, Gilbert) ✓ Vascularized bone
from the toe (Buback) Microvascular transfer (Morrison) Free bone graft (Tubiana, Gilbert) ✓ Vascularized bone
from the toe (Buback) Microvascular transfer (Morrison) Free bone graft (Tubiana, Gilbert) ✓ Vascularized bone
from the toe (Buback) Microvascular transfer (Morrison) Free bone graft (Tubiana, Gilbert) ✓ Vascularized bone

Free bone graft (Tubiana, Gilbert)

transfer (Morrison) Free bone graft (Tubiana, Gilbert) ✓ Vascularized bone (Saffar, Gargollo) ✓ ✓
transfer (Morrison) Free bone graft (Tubiana, Gilbert) ✓ Vascularized bone (Saffar, Gargollo) ✓ ✓

Vascularized bone (Saffar, Gargollo)

Gilbert) ✓ Vascularized bone (Saffar, Gargollo) ✓ ✓ Phalangeal osteotomy (Shepard) Microsurgical
Gilbert) ✓ Vascularized bone (Saffar, Gargollo) ✓ ✓ Phalangeal osteotomy (Shepard) Microsurgical
✓ ✓ Phalangeal osteotomy (Shepard) Microsurgical transfer (Morrison)
Phalangeal osteotomy (Shepard)
Microsurgical transfer (Morrison)
Retrocession flap : Dufourmentel 1963
Retrocession flap : Dufourmentel 1963
Retrocession flap : Dufourmentel 1963 Foucher’s variation
Foucher’s variation
Foucher’s variation
11/16 cases, 50% good results Quality of results was correlated to the importance of bone
11/16 cases, 50% good results Quality of results was correlated to the importance of bone
11/16 cases, 50% good results Quality of results was correlated to the importance of bone
11/16 cases, 50% good results Quality of results was correlated to the importance of bone
11/16 cases, 50% good results Quality of results was correlated to the importance of bone

11/16 cases, 50% good results Quality of results was correlated to the importance of bone loss Interesting in case of scarring pulp

of results was correlated to the importance of bone loss Interesting in case of scarring pulp
of results was correlated to the importance of bone loss Interesting in case of scarring pulp
of results was correlated to the importance of bone loss Interesting in case of scarring pulp
of results was correlated to the importance of bone loss Interesting in case of scarring pulp
of results was correlated to the importance of bone loss Interesting in case of scarring pulp
Dumontier et al, 1989
Dumontier et al, 1989
Antenna’s procedure
Antenna’s procedure
Described in 1983
Described in 1983
Antenna’s procedure Described in 1983 4 cases ( « happy or very happy with the results

4 cases (« happy or very happy with the results », TPD was 4 mm)

( « happy or very happy with the results » , TPD was 4 mm) K-wires
( « happy or very happy with the results » , TPD was 4 mm) K-wires
( « happy or very happy with the results » , TPD was 4 mm) K-wires

K-wires are used to sustain the nail bed

» , TPD was 4 mm) K-wires are used to sustain the nail bed Atasoy E,
» , TPD was 4 mm) K-wires are used to sustain the nail bed Atasoy E,
One other series
One other series
One other series 7 cases reported in children with 5 good and 2 fair results «

7 cases reported in children with 5 good and 2 fair results

7 cases reported in children with 5 good and 2 fair results « In all seven
7 cases reported in children with 5 good and 2 fair results « In all seven

« In all seven patients the deformity was noticeably improved in the opinion of the reviewer and patient. All patients stated that they were pleased with their result in that the appearance was improved and function was good »

in that the appearance was improved and function was good » To my opinion, I disagree
in that the appearance was improved and function was good » To my opinion, I disagree
in that the appearance was improved and function was good » To my opinion, I disagree
in that the appearance was improved and function was good » To my opinion, I disagree
in that the appearance was improved and function was good » To my opinion, I disagree
in that the appearance was improved and function was good » To my opinion, I disagree

To my opinion, I disagree with the choice of the skin flap which quality is « poor ».

the choice of the skin flap which quality is « poor ». Antenna procedure for the
the choice of the skin flap which quality is « poor ». Antenna procedure for the

Antenna procedure for the correction of hook nail deformity. Strick MJ, Bremner-Smith AT, Tonkin MA. J Hand Surg Eur 2004;29B: 1: 3–7

Island flap
Island flap
Island flap
Island flap
Island flap
Island flap
Island flap
Interesting results, however The finger is still shorter
Interesting results, however
The finger is still shorter
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction

Limited results due to undersizing of the pulp with secondary retraction

Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
Limited results due to undersizing of the pulp with secondary retraction
28 patients, 1/3 excellent, 1/3 good, 1/3 fair Results were correlated to bone loss, the
28 patients, 1/3 excellent, 1/3 good, 1/3 fair Results were correlated to bone loss, the
28 patients, 1/3 excellent, 1/3 good, 1/3 fair Results were correlated to bone loss, the

28 patients, 1/3 excellent, 1/3 good, 1/3 fair Results were correlated to bone loss, the cutting edge being 50% bone loss It is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction

is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
is important to over-estimate the skin loss to prevent recurrence due to secondary flap retraction Dumontier
Dumontier et al, 1995
Dumontier et al, 1995
Bony reconstruction ?
Bony reconstruction ?
Bony reconstruction ? Free non-vascularized bone graft absorbs in adults. I have no experience in children

Free non-vascularized bone graft absorbs in adults. I have no experience in children

graft absorbs in adults. I have no experience in children Vascularized bone graft from the distal
graft absorbs in adults. I have no experience in children Vascularized bone graft from the distal
graft absorbs in adults. I have no experience in children Vascularized bone graft from the distal

Vascularized bone graft from the distal phalanx (are probably non- vascularized)

from the distal phalanx (are probably non- vascularized) Phalangeal osteotomy could be considered only if bone
from the distal phalanx (are probably non- vascularized) Phalangeal osteotomy could be considered only if bone
from the distal phalanx (are probably non- vascularized) Phalangeal osteotomy could be considered only if bone

Phalangeal osteotomy could be considered only if bone loss is limite (No pictures are available in the paper, only drawings)

osteotomy could be considered only if bone loss is limite (No pictures are available in the
osteotomy could be considered only if bone loss is limite (No pictures are available in the
osteotomy could be considered only if bone loss is limite (No pictures are available in the
osteotomy could be considered only if bone loss is limite (No pictures are available in the
Microsurgical transfers
Microsurgical transfers
1980
1980
Microsurgical transfers 1980 MORRISON wrap-around flap 1980 FOUCHER wrap-around modified 1988 KOSHIBA free

MORRISON wrap-around flap

1980 FOUCHER
1980 FOUCHER
wrap-around modified
wrap-around modified
1988
1988
wrap-around flap 1980 FOUCHER wrap-around modified 1988 KOSHIBA free arterialized nail flap 1990 NAKAYAMA

KOSHIBA free arterialized nail flap

modified 1988 KOSHIBA free arterialized nail flap 1990 NAKAYAMA arterialized venous nail 1996 ENDO short
modified 1988 KOSHIBA free arterialized nail flap 1990 NAKAYAMA arterialized venous nail 1996 ENDO short

1990 NAKAYAMA arterialized venous nail

nail flap 1990 NAKAYAMA arterialized venous nail 1996 ENDO short pedicled-arterialized nail flap HIRASE
nail flap 1990 NAKAYAMA arterialized venous nail 1996 ENDO short pedicled-arterialized nail flap HIRASE
1996
1996
nail flap 1990 NAKAYAMA arterialized venous nail 1996 ENDO short pedicled-arterialized nail flap HIRASE

ENDO short pedicled-arterialized nail flap HIRASE modified twisted-toe flap transfer

venous nail 1996 ENDO short pedicled-arterialized nail flap HIRASE modified twisted-toe flap transfer 1997
1997
1997
venous nail 1996 ENDO short pedicled-arterialized nail flap HIRASE modified twisted-toe flap transfer 1997
venous nail 1996 ENDO short pedicled-arterialized nail flap HIRASE modified twisted-toe flap transfer 1997
Example (adult)
Example (adult)
Example
Example
(adult)
(adult)
Example (adult)
Example (adult)
Surgical indications for hook- nail deformity (in my opinion) Depends of : Bone loss: <

Surgical indications for hook- nail deformity (in my opinion)

Surgical indications for hook- nail deformity (in my opinion) Depends of : Bone loss: < 50%
Surgical indications for hook- nail deformity (in my opinion) Depends of : Bone loss: < 50%
Depends of :
Depends of :
for hook- nail deformity (in my opinion) Depends of : Bone loss: < 50% (soft-tissue), >
for hook- nail deformity (in my opinion) Depends of : Bone loss: < 50% (soft-tissue), >

Bone loss: < 50% (soft-tissue), > 50% consider microsurgery if:

< 50% (soft-tissue), > 50% consider microsurgery if: Pulp loss Thumb (> finger) Local vascularity (Age
Pulp loss
Pulp loss
Thumb (> finger)
Thumb (> finger)
Local vascularity (Age +++, smoker)
Local vascularity (Age +++, smoker)
Functional needs (Musicians, )
Functional needs (Musicians,
)
Take home message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures
Take home message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures
Take home message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures

Take home message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail plate

message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail
message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail
message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail
message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail
message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail
message: Best treatment relies on prevention: reconstruction in emergency of the supportive structures of the nail

PINCER NAILS

PINCER NAIL

• Is a transverse overcurvature of the nail plate progressively pinching the nail bed distally

• Frequent on toes, rare on fingers

• Mostly females over 40 years old

toes, rare on fingers • Mostly females over 40 years old First reported in 1950 by

First reported in 1950 by Frost. Cornelius and Shelley introduced the term “pincer nail” in 1968.

CAUSES OF PINCER NAILS

Hereditary (almost always symmetrical)

Acquired :

Dermatoses, most often psoriasis or Tinea ungium due to Trichophyton rubrum,

Tumors such as exostosis, implantation cyst, or myxoid cyst

AV fistula (nail changes are restricted to the index and little fingers).

Some blockers such as practolol 7 and acebutolol.

In association with a metastasing adenocarcinoma of the sigmoid colon.

with a metastasing adenocarcinoma of the sigmoid colon. • In the foot as a result of

In the foot as a result of ill- fitting shoes.

In fingers in degenerative osteoarthritis of the DIPj

colon. • In the foot as a result of ill- fitting shoes. • In fingers in
Three types have been described
Three types have been described

Three types have been described

PATHOPHYSIOLOGY

Overcurvature is most probably due to an enlarged base of the distal phalanx to which the matrix is firmly bound by ligament-like collagen fibers.

Since toenails are markedly curved, the curvature of the proximal (matricial) nail plate portion will decrease and consequently the curvature will increase distally

of the proximal (matricial) nail plate portion will decrease and consequently the curvature will increase distally
of the proximal (matricial) nail plate portion will decrease and consequently the curvature will increase distally

CLINICAL CONSEQUENCES

The nail bed becomes pinched, shrinks in its transverse diameter, and is lifted up distally

The lateral plate margins may break through the epidermis and produce granulation tissue mimicking an ingrown toe- nail.

Cutting the nail may become more and more difficult and painful

Frequently associated with thickening of the nail plate.

the nail may become more and more difficult and painful • Frequently associated with thickening of

CONSERVATIVE TREATMENT

Frequently reported: application of urea, grinding of the nail plate, clipping, grooving, thinning, and orthonyx with steel or plastic braces

Almost all patients experienced recurrences, usually in only about half the time needed to correct the pincer nail (Baran).

all patients experienced recurrences, usually in only about half the time needed to correct the pincer
all patients experienced recurrences, usually in only about half the time needed to correct the pincer

SURGICAL TREATMENT

Nail plate ablation:To be avoided as it does not treat the cause and aggravates patients

Removal of the lateral matrix horn (or cauterization with phenol) is the simplest, least painful, but nevertheless a sufficiently effective and simpler than removal of osteophytes (especially indicated in the plicated type)

nevertheless a sufficiently effective and simpler than removal of osteophytes (especially indicated in the plicated type)
nevertheless a sufficiently effective and simpler than removal of osteophytes (especially indicated in the plicated type)

HANEKE’S TECHNIQUE

The nail bed is cut by a median longitudinal incision and the soft tissues are dissected from the terminal phalanx.

Reversed tie-over sutures are put in the lateral nail folds and tied over a pad on the plantar aspect of the toe in order to spread the nail bed.

Suturing the nail bed and inserting a small plastic plate between the curved nail plate and the flattened resutured nail bed

However the scar may leave a split nail and results are not permanent according to the author

resutured nail bed • However the scar may leave a split nail and results are not

ONE SINGLE SERIES HAS BEEN PUBLISHED USING DERMAL GRAFTS

Brown RE, Zook EG,Williams J: Correction of pincer-nail deformity using dermal grafting. Plast Reconstr Surg 2000; 105:1658 –1661.

Zook EG, Chalekson CP, Brown RE, Neumeister MW. Correction of Pincer- Nail Deformities With Autograft or Homograft Dermis: Modified Surgical Technique. J Hand Surg 2005;30A:400–403

« Forty-nine sides (paronychial folds) were dissected off the distal phalanx periosteum with scissors and/or a small elevator.The dermis was placed between the paronychial fold and the phalanx to flatten the germinal and sterile matrix. Direct comparison of autograft dermis to homograft dermis did not show any significant differences in postcorrection appearance of the nail or relief of symptoms"

SPLIT NAILS

SPLIT NAILS

NAIL BED INJURIES

Scars or loss of nail bed will lead to adhesion problems Onycholysis Nail fragility (onychoschizy)
Scars or loss of nail bed will lead to
adhesion problems
Onycholysis
Nail fragility (onychoschizy)
Splints, grooves

NAIL MATRIX DESTRUCTION

A nail matrix loss (or a scar) cannot produce nail plate The nail plate will
A nail matrix loss (or a scar)
cannot produce nail plate
The nail plate will present
either a ridge or will be
divided in two parts

NAIL MATRIX DESTRUCTION

If the scar also concerns the proximal nail fold, one will observe a pterygium The
If the scar also concerns the
proximal nail fold, one will
observe a pterygium
The maximum nail matrix loss
giving no sequelae is around 2-3
mm

SPLIT NAIL DUE TO NAIL BED INJURIES

SPLIT NAIL DUE TO NAIL BED INJURIES If nail bed loss is limited (2-3 mm): Central

If nail bed loss is limited (2-3 mm):

Central loss: Undermine the nail bed from the phalanx and bring the two edges together. If necessary, a contra incision can be made at the junction of the lateral nail wall and nail bedTO NAIL BED INJURIES If nail bed loss is limited (2-3 mm): Lateral loss: resect the

Lateral loss: resect the proximal matrix and shorten nail widththe two edges together. If necessary, a contra incision can be made at the junction of

made at the junction of the lateral nail wall and nail bed Lateral loss: resect the

IF LOSS IS > 2-3 MM: CONSIDER NAIL BED GRAFTING

If the nail bed can sometimes be replace by another tissue in emergency It can
If the nail bed can sometimes be replace by another
tissue in emergency
It can only be replace by a nail bed graft for
reconstruction
Great from the same nail :Very limited possibilities
Graft from the great toe

DONOR SITE

The great toe The blade must be seen during removal (< 300 µ) Take care
The great toe
The blade must be seen during
removal (< 300 µ)
Take care of the nail convexity
25% sequelae at the donor site
1 yr 2 years
1 yr
2 years
Distal onycholysis treated with nail bed graft

Distal onycholysis treated with nail bed graft

Distal onycholysis treated with nail bed graft
Distal onycholysis treated with nail bed graft

RESULTS OF NAIL BED GRAFTS

3 yrs 4 published series (< 10 cas) 60-70% good results Failures were due to:
3 yrs
4 published series (< 10 cas)
60-70% good results
Failures were due to:
Unknown (secondary) infection
Associated matrix involvement
SPLIT NAIL DUE TO NAIL MATRIX DESTRUCTION We need some matrix tissues !

SPLIT NAIL DUE TO NAIL MATRIX DESTRUCTION

SPLIT NAIL DUE TO NAIL MATRIX DESTRUCTION We need some matrix tissues !
SPLIT NAIL DUE TO NAIL MATRIX DESTRUCTION We need some matrix tissues !

We need some matrix tissues !

SPLIT NAIL DUE TO NAIL MATRIX DESTRUCTION We need some matrix tissues !
SPLIT NAIL DUE TO NAIL MATRIX DESTRUCTION We need some matrix tissues !

TWO POSSIBILITIES

Limited, central nail matrix loss Translational flaps (same as described for nail bed losses) Large
Limited, central nail matrix loss
Translational flaps (same as
described for nail bed losses)
Large matrix loss
Partial nail matrix grafts
(including proximal nail fold)

NAIL MATRIX LOSS AND PTERYGIUM

Double treatment: Nail matrix reconstruction Excision + suture if limited loss (2-3 mm) Plus nail
Double treatment:
Nail matrix reconstruction
Excision + suture if limited loss (2-3 mm)
Plus nail fold reconstruction with a split thickness
nail bed graft under the fold
Partial nail matrix graft + nail fold
No series available
Split-thickness graft of a nail wall for treatment of a pterygium
Split-thickness graft of a nail wall for treatment of a pterygium
Split-thickness graft of a nail wall for treatment of a pterygium

Split-thickness graft of a nail wall for treatment of a pterygium

Split-thickness graft of a nail wall for treatment of a pterygium
PARTIAL NAIL MATRIX GRAFT
PARTIAL NAIL MATRIX GRAFT

PARTIAL NAIL MATRIX GRAFT

PARTIAL NAIL MATRIX GRAFT
PARTIAL NAIL MATRIX GRAFT
3 years
3 years

PARTIAL MATRIX GRAFT IS AN EVOLUTION OF COMPLETE NAIL GRAFT

According to Flint, partial nail matrix always fail (not exactly true)PARTIAL MATRIX GRAFT IS AN EVOLUTION OF COMPLETE NAIL GRAFT Shepard reported of 8 cases of

Shepard reported of 8 cases of «en bloc» nail unit graftto Flint, partial nail matrix always fail (not exactly true) Sellah (2000) reported of 14 cases

Sellah (2000) reported of 14 cases without late resorbtion and 11 good resultsmatrix always fail (not exactly true) Shepard reported of 8 cases of «en bloc» nail unit

We have done three casesof 8 cases of «en bloc» nail unit graft Sellah (2000) reported of 14 cases without

nail unit graft Sellah (2000) reported of 14 cases without late resorbtion and 11 good results
Limitations: toenail does not have the same shape or length
Limitations: toenail does not have the same shape or length
SOME OTHER NAILS DYSTROPHIES

SOME OTHER NAILS DYSTROPHIES

HYPONYCHIAL

LOSS

Very frequentHYPONYCHIAL LOSS After distal pulp loss (i.e. fingertip amputation w/wo reconstruction with a flap) Patient complains

After distal pulp loss (i.e. fingertip amputation w/wo reconstruction with a flap)HYPONYCHIAL LOSS Very frequent Patient complains of pain when pulling on their pulp or when trying

Patient complains of pain when pulling on their pulp or when trying to cut their nailsHYPONYCHIAL LOSS Very frequent After distal pulp loss (i.e. fingertip amputation w/wo reconstruction with a flap)

w/wo reconstruction with a flap) Patient complains of pain when pulling on their pulp or when

HYPONYCHIAL

LOSS

Treatment is easy:HYPONYCHIAL LOSS remove the distal scar at the end of the nail bed And place a

remove the distal scar at the end of the nail bed

And place a small skin graft on which the nail cannot adhereHYPONYCHIAL LOSS Treatment is easy: remove the distal scar at the end of the nail bed

No series publishedis easy: remove the distal scar at the end of the nail bed And place a

distal scar at the end of the nail bed And place a small skin graft on
NAIL FOLD INJURIES

NAIL FOLD INJURIES

NAIL FOLD INJURIES

LATERAL NAIL FOLD RECONSTRUCTION

Loss of lateral nail fold induces nail malrotation deformity and/or painful pinch and/or ingrowing nail
Loss of lateral nail fold induces nail malrotation
deformity and/or painful pinch and/or ingrowing
nail
Lateral skin flaps is the only solution
But few are available

PROXIMAL NAIL FOLD RECONSTRUCTION

Many skin flaps mostly designed for burn injuries Two tricks: graft the donor site +
Many skin flaps mostly designed for burn injuries
Two tricks: graft the donor site + nail bed graft on the
inferior part of the nail fold +++
Some examples
Some examples
Some examples
Some examples
Some examples

Some examples

SOME

ENDING

REMARKS

SOME ENDING REMARKS

AFTER 33 YEARS INTERESTING IN NAILS

Most of the reported techniques have short follow- up, No real series published for most
Most of the reported techniques have short follow-
up,
No real series published for most techniques
In my experience, fair results and failures are not rare
We can improve patient, rarely can we give them a
normal nail

SO TO AVOID NAIL DYSTROPHIES

Prevention Quality of the first treatment: Respect the nail unit Do immediate reconstruction when needed
Prevention
Quality of the first treatment:
Respect the nail unit
Do immediate reconstruction when needed

All those patients have been treated in a Hand unit !

All those patients have been treated in a Hand unit !
All those patients have been treated in a Hand unit !
All those patients have been treated in a Hand unit !
All those patients have been treated in a Hand unit !
All those patients have been treated in a Hand unit !

DO NOT FORGET

Prosthesis that gives a beautiful cosmetic results !
Prosthesis that gives a beautiful cosmetic results !
Many thanks to Dr Lindsay MUIR and the BSSH for your invitation Thanks for your

Many thanks to Dr Lindsay MUIR and the BSSH for your invitation

Many thanks to Dr Lindsay MUIR and the BSSH for your invitation Thanks for your attention
Many thanks to Dr Lindsay MUIR and the BSSH for your invitation Thanks for your attention

Thanks for your attention