Updated: 5/14/2017

Hook Nail Deformity

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Introduction
  • Clinical definition
    • nail deformity that occurs caused by volar curving of the nail matrix
  • 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 
Treatments
  • 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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