Updated: 5/9/2017

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
  • 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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