Figure 937

The Winograd procedure, (a) tissue for excision (b) a 'D' shaped incision is made including the nail matrix and overlying soft tissues (c) post-operative appearance .

occasion, pain may develop specifically under the midpoint of the distal nail edge, dorsal to the distal phalangeal tuft. Two varieties of overcurvature can be described:

1 Symmetrical involvement of several toes, usually with lateral deviation of the long axis of the hallux nail and medial deviation of the lesser toe nails (Figure 9.38). This variety is probably genetically determined. The pincer nail syndrome includes gryphosis of finger and toe nails in combination with acro-osteolytic shortening of the terminal phalanx and destructive arthrosis of the distal joints of the digits. An X-ray examination reveals a wider base of the terminal phalanx, often with lateral osteophytes. Hyperostosis is frequently observed on the dorsal tuft of the distal phalanx, due to traction of the heaped-up nail bed which is firmly attached to the bone by collagen fibres. 2 Asymmetrical involvement of the halluces, the major cause being foot deformities and osteoarthritis (Figure 9.39).

Conservative management is suitable for mild to moderate deformity, which may be

Figure 9.38

Pincer nail deformity with symmetrical involvement of several toes.

Figure 9.38

Pincer nail deformity with symmetrical involvement of several toes.

Figure 9.39

Involuted or trumpet nail—often painful.

Figure 9.39

Involuted or trumpet nail—often painful.

improved by simple resection of the involuted shoulders of nail with clearance of any underlying onychophosis—relief is usually instant. Any thickening of the nail plate itself can be reduced using a nail drill. Advice should also be given regarding footwear with a deep toe box to eliminate dorsal pressure on the nail. More severe deformity may benefit from a nail brace technique which is based on maintaining tension on the nail plate with the wire. Fraser's method consists of a brace constructed to fit the curved plate exactly; at one selected point a minute adjustment (a slight bend) is then made to the brace and it is fitted to the plate. As the nail plate is weaker than the stainless wire, the nail plate conforms to the brace. In the months that follow, a series of adjustments are made and almost imperceptibly the curvature decreases. Some improvements to this technique have been suggested, such as the use of brackets adapted on the dorsum of the nail and linked by a rubber band or attachment of a plastic brace on the surface of the nail. In these cases the nail plate is first flattened with an electric nail drill, and pliant braces are stuck transversely on the nail to counteract the overcurvature (Figure 9.40). However, the

Figure 9.40

(a-d) Nail brace technique for pincer nail deformity.

Figure 9.40

(a-d) Nail brace technique for pincer nail deformity.

Figure 9.41

(a, b) Haneke's technique for correcton of pincer nail deformity.

Figure 9.41

(a, b) Haneke's technique for correcton of pincer nail deformity.

pathogenesis of pincer nail is such that none of these methods gives a high cure rate.

The definitive procedure is said to be Haneke's surgical treatment (Figure 9.41): using a bloodless field, a lateral nail strip involving one or both sides is freed from the proximal nail fold, nail bed and matrix with a Freer septum elevator, then cut longitudinally and extracted. This permits the destruction of the lateral matrix horns by phenol. The distal two-thirds of the nail is removed, then a longitudinal median incision of the nail bed is carried down to the bone. The entire nail bed is dissected from the phalanx and the dorsal tuft removed with a bone rongeur. The nail bed is spread and sutured with 6-0 polydioxanone atraumatic sutures and kept in this position by reversed tie-over sutures that pull the lateral nail folds apart; these are left in for 18-21 days. Daily povidone-iodine antisepsis prevents infection.

Distal nail embedding

In the great toe, a distal wall may develop after nail shedding following subungual haemorrhage, for example in tennis toe or after nail avulsion (Figure 9.42). Normally, the nail plate position counteracts the forces that are exerted during walking. Owing to lack of counterpressure, the plantar portion of the hallux pulp becomes distorted dorsally when the foot rolls up and the body weight presses on the tip of the great toe during walking. The distal wall interferes with the growth of the newly formed nail. The anchoring of an acrylic sculptured nail on the stump nail may enable it to overgrow the heaped-up distal tissue (Figure 9.43). Should this procedure not be effective a crescent-shaped wedge excision becomes necessary (Figure 9.44). A 'fish

Figure 9.42

Distal nail embedding—overgrowth of distal soft tissue after nail loss. New nail may penetrate into this.

Figure 9.42

Distal nail embedding—overgrowth of distal soft tissue after nail loss. New nail may penetrate into this.

Figure 9.43

Anchoring of acrylic sculptured nail to inhibit embedding.

Figure 9.43

Anchoring of acrylic sculptured nail to inhibit embedding.

Figure 9.44

(a, b) Removal of overgrown distal soft tissue.

Figure 9.44

(a, b) Removal of overgrown distal soft tissue.

mouth' incision is carried out parallel to the distal groove around the tip of the toe, starting and ending 3-5 mm proximal to the end of the lateral nail fold. A second incision is then made to yield a wedge of 4-8 mm at its greatest width; it has to be dissected from the bone.

Hangnails

Hangnails often result from self-inflicted trauma. Usually limited to the hands, these consist of a small portion of horny epidermis that has split away from the lateral nail fold. They can be painful and lead to secondary bacterial infection. Although frequently found in nail biters, they can also arise from other forms of injury. Cuticle biting and picking may result in recurrent attacks of paronychia.

Paronychia of the toes

Inflammation of the nail folds is common in athletes and is characterized by swelling, erythema, pain and purulent discharge. It is often caused by pressure from the shoe or by secondary infection from ingrowing toe nail. The big toe is more often affected than the lesser toes. Turf toe is a variant of this condition described in competitors who play on artificial turf surfaces; rarely, they develop painful erythema and swelling, mainly of the great toe.

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