Introduction Clinical definition nail deformity that occurs caused by volar curving of the nail matrix Etiology Pathophysiology can be caused by tight closure of the fingertip during treatment fo distal tip amputation loss of bony support under the nail bed causing volar sloping of the nail bed Anatomy Perionychium consists of nail bed login to view 7 more bullets nail fold login to view 3 more bullets eponychium login to view 1 more bullet paronychium login to view 1 more bullet hyponychium login to view 1 more bullet Presentation History patient will report fingertip injury in the form of trauma or infection in the past Symptoms common symptoms painless complaint is typically cosmetic in nature can become painful if it becomes in-grown Physical exam Careful inspection of the nail to identify any 'hooking' of the nail Imaging Radiographs typically needed to assess the bone stock/deformity of the distal phalanx tuft Treatment Nonoperative observation alone indications login to view 1 more bullet prosthetic replacement Operative indications improving cosmesis painful, in-grown hook nail soft tissue manipulation - shorten bone, do not maintain nail bed length indications login to view 2 more bullets soft tissue + bony support - lengthen bone, maintain nail bed length indications login to view 1 more bullet Technique Soft tissue manipulation shorten bone, perform soft tissue procedure to correct 'hooking' of nail bed that advances soft tissue and reattach to dorsum of bone V-Y advancement cross-finger flap full-thickness skin graft Bony support procedure to maintain nail length options bone graft to distal tip free, vascularized bone graft from second toe Complications Lack of complete correction Recurrence of deformity Necrosis/flap failure, loss of distal tip