ICHS January 2020 series 8, Course 1

DISORDERS OF THE NAIL

(HOOK NAIL, PINCER NAIL,
SPLIT NAIL, OTHERS,…)
Can be downloaded on www.diuchirurgiemain.org

Christian Dumontier, MD, PhD

With the help of Dr Sylvie Carmès
Centre de la Main, Guadeloupe, FWI
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)
✓ Hetero-digital flap (Atasoy)
• Supply with ✓ Island flap (Gilbert, Tubiana)
soft-tissue ✓ Composite graft from the toe (Buback)
✓ Microvascular transfer (Morrison)

✓ Free bone graft (Tubiana, Gilbert)

✓ Vascularized bone (Saffar, Gargollo)
• Bony support ✓ 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 ».

Strick MJ, Bremner-Smith AT, Tonkin MA. Antenna procedure for the correction of hook nail deformity. 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 limited
(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"
1 year FU
SPLIT NAILS
 NAIL BED INJURIES

Scars or loss of nail bed will lead to

adhesion problems

Onycholysis

Nail fragility (onychoschizis)

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

Graft 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 35 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 the BSSH for your
invitation

Thanks for your

attention