Updated: 5/22/2021

Hook Nail Deformity

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  • 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
          • 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
        • 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
          • majority of patients not concerned about cosmesis
      • prosthetic replacement
    • Operative
      • indications
        • improving cosmesis
        • painful, in-grown hook nail
      •  soft tissue manipulation - shorten bone, do not maintain nail bed length
        • indications
          • majority of distal tuft maintained
          • when the distal nail bed has been closed/pulled over the distal tuft
      • soft tissue + bony support - lengthen bone, maintain nail bed length
        • indications
          • lack of distal tuft/bony support
  • 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
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