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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

BSSH Instructional
courses - series 7
HOOK-NAIL DEFORMITY
Shape of the nail
The shape of the nail plate
depends of:
The bony support
The volume of the pulp
The orientation of the nail
matrix/bed
Quality of the nail walls
Volar inclination of the nail is secondary to:
Bone loss
Pulp retraction/loss
Treatment can only be surgical
Possible surgical techniques

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

Low level of evidence !
Proposed techniques
✓ Retrocession flap (Dufourmentel)
✓ Excision of nail bed (Kumar)
Supply with soft- ✓ Hetero-digital flap (Atasoy)
tissue ✓ Island flap (Gilbert, Tubiana)
✓ Composite graft from the toe (Buback)
✓ Microvascular transfer (Morrison)

✓ Free bone graft (Tubiana, Gilbert)
Bony support ✓ Vascularized bone (Saffar, Gargollo)
✓ Phalangeal osteotomy (Shepard)
✓ Microsurgical transfer (Morrison)
Retrocession flap : Dufourmentel 1963

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

Dumontier et al, 1989
Antenna’s procedure

Described in 1983

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

K-wires are used to
sustain the nail bed

Atasoy E, Godfrey A, Kalisman M. The « antenna » procedure for the « hook-nail » deformity. J
Hand Surg 1983; 8:55-8.
One other series
7 cases reported in children with 5 good and 2 fair
results
« 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 »
To my opinion, I disagree with the choice of the skin flap
which quality is « poor ».

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
Interesting results, however

The finger is still shorter
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 cutting edge being 50%
bone loss
It is important to over-estimate
the skin loss to prevent recurrence
due to secondary flap retraction

Dumontier et al, 1995
Bony reconstruction ?
Free non-vascularized bone graft
absorbs in adults. I have no
experience in children
Vascularized bone graft from the
distal phalanx (are probably non-
vascularized)
Phalangeal osteotomy could be
considered only if bone loss is
limite (No pictures are available in
the paper, only drawings)
Microsurgical transfers

1980 MORRISON wrap-around flap

1980 FOUCHER wrap-around modified

1988 KOSHIBA free arterialized nail flap

1990 NAKAYAMA arterialized venous nail

1996 ENDO short pedicled-arterialized nail flap

1997 HIRASE modified twisted-toe flap transfer
Example
(adult)
Surgical indications for hook-
nail deformity (in my opinion)

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

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 and acebutolol.
7

• In association with a metastasing adenocarcinoma of the sigmoid colon.

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

• In fingers in degenerative
osteoarthritis of the DIPj
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
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.
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).
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)
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
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
NAIL BED INJURIES

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 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 maximum nail matrix loss
giving no sequelae is around 2-3
mm
SPLIT NAIL DUE TO NAIL
BED INJURIES
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 bed

Lateral loss: resect the proximal
matrix and shorten nail width
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 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 of the nail convexity

25% sequelae at the donor site
1 yr

2 years
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:

Unknown (secondary) infection

Associated matrix involvement
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 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 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
PARTIAL NAIL MATRIX GRAFT
3 years
PARTIAL MATRIX GRAFT IS AN
EVOLUTION OF COMPLETE NAIL GRAFT

According to Flint, partial nail
matrix always fail (not exactly
true)

Shepard reported of 8 cases of «en
bloc» nail unit graft

Sellah (2000) reported of 14 cases
without late resorbtion and 11
good results

We have done three cases
Limitations: toenail does not have the same shape or length
SOME OTHER NAILS
DYSTROPHIES
HYPONYCHIAL
LOSS

Very frequent

After distal pulp loss (i.e. fingertip
amputation w/wo reconstruction
with a flap)

Patient complains of pain when
pulling on their pulp or when
trying to cut their nails
HYPONYCHIAL
LOSS

Treatment is easy:
remove the distal scar at
the end of the nail bed

And place a small skin
graft on which the nail
cannot adhere

No series published
NAIL FOLD
INJURIES
LATERAL NAIL FOLD
RECONSTRUCTION

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 + nail bed graft on the
inferior part of the nail fold +++
Some examples
SOME
ENDING
REMARKS
AFTER 33 YEARS INTERESTING IN NAILS

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
All those patients have been treated in a Hand unit !
DO NOT FORGET

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

Thanks for your
attention