Updated: 5/22/2021

Split Nail Deformity

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  • Introduction
    • Clinical definition
      • scar that produces an 'empty' or 'blank' longitudinal area of nail between two normal regions of nail
  • Etiology
    • Pathophysiology
      • caused by scar in the germinal matrix that causes absence of nail production
      • can occur as a sequelae of
        • nail bed injuries
        • infections (i.e. paronychia)
  • Anatomy
    • Perionychium
      • consists of
        • nail bed
          • soft tissue beneath the nail includes
            • germinal matrix (proximal)
              • produces 90% of the nail
              • scarring causes absence
            • sterile matrix (distal)
              • keeps nail adherent to nail bed
              • injury causes deformity
        • nail fold
          • most proximal portion of the perionychium consists of
            • ventral floor - germinal matrix portion of the nail bed
            • dorsal roof
        • eponychium
          • skin proximal to the nail that covers the nail fold
        • paronychium
          • skin on each side of the nail
        • hyponychium
          • skin distal to the nail bed
  • 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
    • Physical exam
      • careful inspection of the nail to identify any 'blank' areas of nail
  • Imaging
    • Radiographs
      • not typically warranted
      • obtain if suspicious of underlying bony etiology
  • Treatment
    • Nonoperative
      • observation alone
        • indications
          • majority of patients not concerned about cosmesis
    • Operative
      • scar resection and primary closure
        • indications
          • size < 2mm
          • patients have strong desire to improve cosmesis
      • scar resection and full thickness nail bed graft from second toe
        • indications
          • germinal matrix and size >2mm
          • sterile matrix, any size
            • resection and primary closure rarely successful
          • patients have strong desire to improves cosmesis
  • Techniques
    • Scar resection and primary closure
      • indicated for germinal matrix if size <2mm
    • Scar resection and full thickness nail bed graft from second toe
      • preferred for geminal matrix if size > 2mm
  • Complications
    • Recurrence of split nail
    • Persistent cosmetic deformity
    • Donor site morbidity
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