HOOK-NAIL DEFORMITY

S u r g i c a l t r e a t m e n t w i t h a h o m o d i g i t a l a d v a n c e m e n t flap
C. DUMONTIER, A. GILBERT and R. TUBIANA
From the Institut de la Main, Paris, France

Sixteen patients presenting 18 hook-nail deformities have been treated by the advancement of a
homodigital island flap. With an average follow-up of 31 months; Results were considered good
or excellent in seven eases, fair in seven and poor in four. Six cases, although improved, had a
marked recurrence of the deformity, six had a partial recurrence and six had almost no recurrence.
Patient satisfaction was limited as the finger still had a short nail and a square shape.

Journal of Hancl Surgery (British and European Volume, 1995) 20B 6:830-835
Hook-nail deformity is a frequent and disabling posttraumatic problem. Although many techniques have
been published (Table 1), we are only aware of one
publication with detailed results (Dumontier et al, 1989).
We are now using a homodigital advancement flap to
sustain the nail and nail bed and present the results of
surgical treatment of 16 patients (18 nails).

phalanx until the distal insertion of the extensor tendon

is seen. If the nail bed remains convex, we fix it with
one to three fine K-wires either through the nail plate
or under it as proposed by Atasoy et al (1983; Figs 2
and 3). A homodigital advancement flap is designed on
the ulnar side of the digit, or on the radial side of the
little finger, to fill the defect. The flap extends from the
dorsal incision to the middle of the pulp and to the DIP
joint (Fig 3). A full-thickness skin graft is preferred to
fill the donor defect. Dynamic extension splinting is
used after 1 week until recovery of complete active
extension. K-wires are removed at 3 weeks.

SURGICAL T E C H N I Q U E
Under tourniquet control, the entire nail-bed is elevated
using a fish-mouth incision which is continued to the
level of the DIP joint. At least 1 mm of skin is to be
respected on the lateral nail fold to allow for reconstruction of the lateral fold. As the nail plate is bent, it has
to be removed. However this may weaken the nail bed
a s nail plate avulsion removes an important stabilizer.
We favour division of the nail plate with a saw into
three strips to make it flexible and sometimes resect a 2
to 3 mm strip of nail (Fig 1). Using an 11 blade the nail
bed and matrix are then elevated en bloc from the distal

MATERIAL AND RESULTS

Sixteen patients (18 nails) treated with this technique
have been reviewed. Data are summarized in Table 2.
Except for obvious failures, 1 year follow-up was the
minimal requirement for results which are summarized
in Table 3. There were six recurrences, six partial
improvement (Fig4) and six with good correction of

Table 1--Surgical techniques for treatment of hook-nail deformity

Surgical
technique
Nail excision
Soft tissue
reconstruction

Technical variations

Authors

Composite toe graft

Advancement flap
Reverse-flow flap
Homodigital island flap

Bone graft

Cross-finger flap
Non-vascularized
Osteotomy
Osteo-cutaneous island flap
Osteo-cutaneous advancement flap

Nail recession
"Caterpillar" flap
"Escalator" flap
Partial toe
transfer
NA: Number of cases non-available.
830

Number
of cases

Verdan, 1978
Bubak et al, 1992

NA
9

Kojima et al, 1994

Kaji et al, 1991
Shepard, 1990
Our series
Atasoy et al, 1983
Tubiana, 1986
Verdan, 1978
Shepard, 1990
Saffar and Auclair, 1992
Gargollo et al, 1990
Dufourmentel, 1963
Dumontier et al, 1989
Cantero, 1979
Foucher et al, 1991
Koshima et al, 1992

5
NA
7
18
4
2
NA
7
NA
12
NA
11
NA
4
2

831

HOOK-NAIL DEFORMITY

Fig 1 (a) Schematic drawing of the incisions. (b) Incisions on the

nail plate to make it flexible.

Fig 2

Fig 3

(a) and (b) The advancement flap (F) is brought under the
nail unit. The nail bed is sustained by K-wires, and the nail
itself is straightened by a K-wire.

Fig 4

A fair result. Note the nail r e m n a n t at the limit of the scar.

After correcting the nail bed curvature, the nail is straightened

by a K-wire.

the deformity (Figs 5 and 6). Although it is not statistically significant, in our experience, the greater the bone
loss, the worse the results. Patients with no recurrence
had an average of 37.6% bone loss compared to 58.3%
in patients who had recurred. Three patients presented
with ectopic nail remnants which required secondary
excision (Fig 4). These nail remnants were lateral, and
were probably due to division of the proximal germinal
matrix during dissection of the nail bed.
DISCUSSION
Although most patients were improved by our technique,
objective results were somewhat disappointing. The nails
were still short and still had a tendency to bend toward
the pulp which had a square shape. Limited motion was

noted at the DIP joint, but for the most part it was the
result of the original injury.
We had no technical complications with our nail
b e d + m a t r i x flap as this flap is vascularized by the
longitudinal anastomoses running from the proximal

832

Fig 5

THE JOURNAL OF HAND SURGERYVOL. 20B No. 6 DECEMBER 1995

A good aesthetic and functional result. However, the pulp

still has a square shape and is smaller than normal.

arcade of the proximal wall. This arcade is made by the

coalition of dorsal arterial branches which arise at the
level of the neck of the middle phalanx (Brunelli and
Brunelli, 1991; Flint, 1955). Two patients presented with
some instability of the nail bed, but this caused no
problems.
Although congenital abnormalities have been reported
as a cause of hook-nail deformity, almost all cases are
post-traumatic (Bubak et al, 1992; Zook, 1990). Kumar
and Satku (1993) recently suggested that hook-nail
deformity only arose if the nail bed was not supported
by bone, and they have not seen it if the nail bed was
trimmed to the level of the bone at the time of injury.

Fig 6

A good aesthetic and functional result.

However, contraction of the pulp due to bums, frostbite,

spontaneous healing of pulp, loss of substance, or suture
under tension of a flap onto the nail bed can cause the
deformity (Atasoy et al, 1983; Dumontier et al, 1989).
Tuft bone loss is usually a predisposing factor, as

Table 2--Clinical data

Case

Sex

5
6
7
8
9
10
11
12
13
14
15
16
17
18

F
F
M
F
M
F
M
M
M
M
F
F
F
M
8M
8F

Age at the
time o f
accident (years)

Age at the
time of
treatment

Finger

1.5
33
?
?
58
24
58
30
19
32
31
2

39
54
55
55
3.5
3
2.5
36
33
35
64
25
60
32
21
34
32
15

middle
middle
ring
little
index
ring
index
middle
middle
index
middle
middle
ring
index
middle
index
middle
index

28.6 yrs
(1.5-58)

33.27 yrs
(2.5-64)

index = 6
middle = 8
ring = 3
little = 1

53
2.5

Side

R
L
L
L
L
R
L
L
R
L
R
R
L
R
R
L
L
R
8R
10L

Cause of the deformity

pulp loss/spontaneous healing

frostbite

% bone loss

33
66
50
75
50

failure of replantation
?
crush injury/amputation other fingers
pulp loss/spontaneous healing
?

75
70
15

pulp loss/spontaneous healing

Amputation
pulp loss/spontaneous healing
crush injury/spontaneous healing
crush injury/triangular advancement flap
Distal amputation/spontaneous healing
Distal amputation/necrosis of advancement flap
Distal amputation

15
50
40
75
30
75
50
60

52.0%
(15-75)

HOOK-NAIL

DEFORMITY

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834

Foucher et at (1986) have not seen a hook-nail deformity

after conservative treatment of pulp amputation without
exposed bone. If bone and nail bed loss are associated,
nail dystrophy has been observed in 50% of cases, half
of which have hook-nail deformities (Allen, 1980; Holm
and Zachariae, 1974). According to Chow and Ho
(1982), hook-nail deformities are rare if only the distal
third of the nail bed is involved, but if the distal twothirds are involved, 50% of the patients will develop a
hook-nail deformity. The deformity was also frequent
after pulp reconstruction with a homodigital flap, as in
two of our cases (Kapandji et al, 1991). Illingworth
(1974) and Das and Brown (1978) have postulated that
some regeneration of the pulp could limit the frequency
of hook-nail deformity in children, but this has not been
our experience as half of our patients were children at
the time of injury in our first series (Dumontier et al,
1989).
At least five standard models of techniques have been
reported in the literature for the treatment of hook-nail
deformity (Table 1). We feel that nail bed and matrix
excision are only indicated after failure of surgical
correction. Soft-tissue reconstruction has been widely
proposed to pad out the pulp and support the nail bed.
We believe that local flaps are not large enough, and
cross-finger flaps are complicated by absence of sensibility and immobilization. Three out of five patients
treated with an advancement flap had a secondary
procedure i~n Kojima's series. Composite toe grafts have
been used with good aesthetic results, but they probably
lack sensibility (Bubak et al, 1992). We prefer a homodigital advancement flap which is a variation of previously
published
flaps
(Venkataswami
and
Subramanian, 1980; Mouchet and Gilbert, 1982). A
reverse-flow flap has been proposed (Kaji et al, 1991),
but its sensibility is limited (Koshima et al, 1992). A
nail recession flap has been described (Dufourmentel,
1963) but with limited results (Dumontier et al, 1989).
Although they were improved, eight out of 11 patients
were disappointed, and the recurrence rate was as high
as 50%. Bone loss greater than 50% was considered to
be a limit to the nail recession flap technique. Technical
modifications of the nail recession flap technique have
been added by Cantero (1979) and Foucher et al (1991 )
but detailed results were not available. As bone loss is
a major component of the deformity, Verdan (1978)
and Tubiana (1986) have suggested the addition of a
cortical bone graft in the treatment of hook-nail deformity. In three cases we have done this but two resorbed
within 3 months. Non-vascularized cortical bone grafts
of the distal phalanx usually resorb when placed at the
tip (Leviet et al, 1985). We believe that a bone graft
may help by adding some fibrous tissue to sustain the
nail bed only during the early weeks, but very rarely use
it now. Some authors have proposed a vascularized
bone graft by including part of the distal phalanx in the
design of the flap (Gargollo et al, 1990; Saffar and
Auclair, 1992). In our experience, these bone grafts are

THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995

very small, difficult to fix, and their vascularity is uncertain. Shepard (1990) stressed the persistence of curvature
of the nail bed and reported seven cases treated by
transverse osteotomy of the distal phalanx. He reported
good results, but there was no details regarding the
length of the phalanx, or any problems with bone
healing. Finally two cases of microsurgical transfer have
been reported for the treatment of hook-nail deformity,
but with limited sensory discrimination (Koshima
et al, 1992).
Hook-nail deformities are not only unsightly but
painful and functionally disturbing as the curved nail
catches objects. However, most patients looked for
cosmetic improvement of their digit and were disappointed by the final result. The deformity was improved,
but the pulp was shorter than normal and did not have
a normal shape. The nail was also smaller, and still
curved. We do believe that the homodigital advancement
flap is a good technique for bone loss less than 50%,
and probably superior to the nail recession flap technique as it gives a bigger and more comfortable pulp.
Bone grafting is probably unnecessary. However, in
young active patients, especially if there is pulp dystrophy, a microsurgical transfer may be indicated. The
best treatment is still prevention of the deformity: pulp
loss of substance with bone loss has to be covered by a
well padded flap without tension at the time of injury.
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HOOK-NAIL DEFORMITY
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835
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,

'

Accepted: 20 Jaly 1995

C. Dumontier, Institut de la Main, 6 Square Jouvenet, F-7516 Paris, France.
1995 The British Society for Surgery of the Hand