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Surgical Correction of Severe Bilateral Thumb Pincer-Nail Deformity
CLINICAL CORNER Surgical Correction of Severe Bilateral Thumb Pincer-Nail Deformity Scott T. VanDuzer, MD, John Taras, MD From the Philadelphia Hand Center, Drexel University School of Medicine, Thomas Jefferson University School of Medicine, Philadelphia, PA.
53-year-old woman presented to the office with a complaint of severe bilateral thumb nail pain and deformity (Fig. 1). She denied previous trauma to the thumb nails and had no history of previous bacterial or fungal infections of the nails. Based on the curvature of the nails, which increased from proximal to distal, a diagnosis of bilateral thumb pincer-nail deformity was made. The patient was scheduled for surgical correction by modification of previously described techniques.1 Beginning with the left thumb a digital block was performed and the affected digit was exsanguinated. The nail plate was sharply removed without damaging the underlying sterile and germinal matrix. The curved nail bed then was elevated off of the underlying distal phalanx (Fig. 2). On the left side a dermal graft was obtained from the hypothenar eminence that was closed primarily. This was harvested as a full-thickness graft that then was de-epithelialized (Figs. 3, 4). The dermal graft was divided into 2 equal pieces and placed in the area of the lateral nail folds, filling in the defects that had been present. The nail bed was sutured back over the graft to the lateral nail folds with 5-0 chromic suture. The nail bed now had a less curved and more natural flattened appear-
A
Figure 1. Bilateral thumb nails.
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The Journal of Hand Surgery
Figure 2. Nail bed elevated off the distal phalanx.
ance (Fig. 5). The curved nail plate was discarded and silicone sheeting was placed into the nail fold as a stent. On the right side a similar procedure was performed; however, instead of harvesting dermal grafting from the patient, a suitably sized piece of collagen graft (Integra LifeSciences Corporation, Plainsboro, NJ) was used in place of the dermal graft. This was accomplished by removing the silicone membrane layer of the collagen graft bilaminate and using only the collagen-glycosaminoglycan matrix component (Fig. 6). This allows the collagen matrix component of the graft to be wholly implanted. This then was positioned as the dermal graft had been into the lateral nail defects. The remainder of the procedure was performed as previously described. The patient reported resolution of the pain and soft-tissue pinching sensation that she had before surgery. The thumb nails have regrown and appear more normal and have a flattened appearance (Fig. 7). There was good adherence between the nail plate and the underlying nail bed.
VanDuzer and Taras / Bilateral Thumb Pincer-Nail Deformity
1547
Figure 3. Hypothenar full-thickness graft being de-epithelialized.
Pincer-nail, or trumpet-nail, deformity has been well described in the literature.1– 4 It is characterized by excessive curvature of the nail plate that is more pronounced distally than proximally.1 Viewed from the tip, the abnormally shaped nail resembles the Greek letter omega (Fig. 1). This abnormal curvature may result in pinching of the underlying nail bed and soft tissue, resulting in chronic pain. The cause of the nail deformity has been variously attributed to a variety of developmental, systemic, acquired, and external agents.1 The deformity must be distinguished from nail distortion resulting from bacterial or fungal infections. It may affect the nails of the hands and the feet and appears to predominantly affect the nails of the thumbs and great toes. Various methods have been described to treat pincer-nail deformity. These include dermal grafting, in a procedure similar to the technique described previously,1 surgical avulsion of the nail plate,2 surgical revision of the nail bed,4 nail leveling with a grinder and application of pliant plas-
Figure 4. Hypothenar donor site.
Figure 5. Graft in place under lateral nail fold and nail bed.
tic plates,5 and nail bed elevation with hard-palate mucosal grafting.6 These various procedures have differing risks and benefits including recurrence of the deformity, nonadherence of the nail plate to the underlying nail bed, and the morbidity and complexity associated with graft donor sites. We report a slight modification of the technique described by Brown et al1 in that the entire nail bed except the germinal matrix is elevated off the distal phalanx. In our patient we also showed our use of the collagen-glycosaminoglycan matrix portion of a collagen graft bilaminate to avoid dermal harvest
Figure 6. Separating the collagen graft (Integra) bilaminate.
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can matrix to avoid dermal harvesting and grafting.
Figure 7. Appearance of bilateral thumb nails 1 year after surgery.
Received for publication August 17, 2006; accepted in revised form August 23, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: John Taras, MD, Philadelphia Hand Center, PC, Orthopedic Surgery, The Benjamin Franklin House, 834 Chestnut St, Suite G-114, Philadelphia, PA 19107; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A09-0021$32.00/0 doi:10.1016/j.jhsa.2006.08.013
References site and grafting. There did not appear to be any noticeable difference in the curvature of the regenerated nail in the digit in which the collagen graft was used compared with the digit in which dermal autografting was used. It is assumed that Alloderm (LifeCell, Branchburg, NJ) also could be used in a similar manner, although we have not used it for treatment of pincer-nail deformity. In this patient we achieved painless and normal-appearing nail contour with good adherence of the nail plate to the nail bed without disrupting the germinal matrix. In addition, we have shown a technique that uses a readily available collagen-glycosaminogly-
1. Brown RE, Zook EG, Williams J. Correction of pincer-nail deformity using dermal grafting. Plast Reconstr Surg 2000; 105:1658-1661. 2. Cornelius CE III, Shelley WB. Pincer nail syndrome. Arch Surg 1968;96:321-322. 3. Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment. Dermatol Surg 2001;27:261-262. 4. Suzuki K, Yagi I, Konodo M. Surgical treatment of pincer nail syndrome. Plast Reconstr Surg 1979;63:570-571. 5. Effendy I, Ossowski B, Happle R. Pincer nail: conservative treatment by attachment of plastic braces. Hautarzt 1993;44: 800-801. 6. Hatoko M, Hiroshi L, Tanaka A, Masamitsu K, Satoshi Y, Katsunori N. Hard-palate mucosal graft in the management of severe pincer-nail deformity. Plast Reconstr Surg 2003;112: 835.
53-year-old woman presented to the office with a complaint of severe bilateral thumb nail pain and deformity (Fig. 1). She denied previous trauma to the thumb nails and had no history of previous bacterial or fungal infections of the nails. Based on the curvature of the nails, which increased from proximal to distal, a diagnosis of bilateral thumb pincer-nail deformity was made. The patient was scheduled for surgical correction by modification of previously described techniques.1 Beginning with the left thumb a digital block was performed and the affected digit was exsanguinated. The nail plate was sharply removed without damaging the underlying sterile and germinal matrix. The curved nail bed then was elevated off of the underlying distal phalanx (Fig. 2). On the left side a dermal graft was obtained from the hypothenar eminence that was closed primarily. This was harvested as a full-thickness graft that then was de-epithelialized (Figs. 3, 4). The dermal graft was divided into 2 equal pieces and placed in the area of the lateral nail folds, filling in the defects that had been present. The nail bed was sutured back over the graft to the lateral nail folds with 5-0 chromic suture. The nail bed now had a less curved and more natural flattened appear-
A
Figure 1. Bilateral thumb nails.
1546
The Journal of Hand Surgery
Figure 2. Nail bed elevated off the distal phalanx.
ance (Fig. 5). The curved nail plate was discarded and silicone sheeting was placed into the nail fold as a stent. On the right side a similar procedure was performed; however, instead of harvesting dermal grafting from the patient, a suitably sized piece of collagen graft (Integra LifeSciences Corporation, Plainsboro, NJ) was used in place of the dermal graft. This was accomplished by removing the silicone membrane layer of the collagen graft bilaminate and using only the collagen-glycosaminoglycan matrix component (Fig. 6). This allows the collagen matrix component of the graft to be wholly implanted. This then was positioned as the dermal graft had been into the lateral nail defects. The remainder of the procedure was performed as previously described. The patient reported resolution of the pain and soft-tissue pinching sensation that she had before surgery. The thumb nails have regrown and appear more normal and have a flattened appearance (Fig. 7). There was good adherence between the nail plate and the underlying nail bed.
VanDuzer and Taras / Bilateral Thumb Pincer-Nail Deformity
1547
Figure 3. Hypothenar full-thickness graft being de-epithelialized.
Pincer-nail, or trumpet-nail, deformity has been well described in the literature.1– 4 It is characterized by excessive curvature of the nail plate that is more pronounced distally than proximally.1 Viewed from the tip, the abnormally shaped nail resembles the Greek letter omega (Fig. 1). This abnormal curvature may result in pinching of the underlying nail bed and soft tissue, resulting in chronic pain. The cause of the nail deformity has been variously attributed to a variety of developmental, systemic, acquired, and external agents.1 The deformity must be distinguished from nail distortion resulting from bacterial or fungal infections. It may affect the nails of the hands and the feet and appears to predominantly affect the nails of the thumbs and great toes. Various methods have been described to treat pincer-nail deformity. These include dermal grafting, in a procedure similar to the technique described previously,1 surgical avulsion of the nail plate,2 surgical revision of the nail bed,4 nail leveling with a grinder and application of pliant plas-
Figure 4. Hypothenar donor site.
Figure 5. Graft in place under lateral nail fold and nail bed.
tic plates,5 and nail bed elevation with hard-palate mucosal grafting.6 These various procedures have differing risks and benefits including recurrence of the deformity, nonadherence of the nail plate to the underlying nail bed, and the morbidity and complexity associated with graft donor sites. We report a slight modification of the technique described by Brown et al1 in that the entire nail bed except the germinal matrix is elevated off the distal phalanx. In our patient we also showed our use of the collagen-glycosaminoglycan matrix portion of a collagen graft bilaminate to avoid dermal harvest
Figure 6. Separating the collagen graft (Integra) bilaminate.
1548
The Journal of Hand Surgery / Vol. 31A No. 9 November 2006
can matrix to avoid dermal harvesting and grafting.
Figure 7. Appearance of bilateral thumb nails 1 year after surgery.
Received for publication August 17, 2006; accepted in revised form August 23, 2006. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: John Taras, MD, Philadelphia Hand Center, PC, Orthopedic Surgery, The Benjamin Franklin House, 834 Chestnut St, Suite G-114, Philadelphia, PA 19107; e-mail: [email protected]. Copyright © 2006 by the American Society for Surgery of the Hand 0363-5023/06/31A09-0021$32.00/0 doi:10.1016/j.jhsa.2006.08.013
References site and grafting. There did not appear to be any noticeable difference in the curvature of the regenerated nail in the digit in which the collagen graft was used compared with the digit in which dermal autografting was used. It is assumed that Alloderm (LifeCell, Branchburg, NJ) also could be used in a similar manner, although we have not used it for treatment of pincer-nail deformity. In this patient we achieved painless and normal-appearing nail contour with good adherence of the nail plate to the nail bed without disrupting the germinal matrix. In addition, we have shown a technique that uses a readily available collagen-glycosaminogly-
1. Brown RE, Zook EG, Williams J. Correction of pincer-nail deformity using dermal grafting. Plast Reconstr Surg 2000; 105:1658-1661. 2. Cornelius CE III, Shelley WB. Pincer nail syndrome. Arch Surg 1968;96:321-322. 3. Baran R, Haneke E, Richert B. Pincer nails: definition and surgical treatment. Dermatol Surg 2001;27:261-262. 4. Suzuki K, Yagi I, Konodo M. Surgical treatment of pincer nail syndrome. Plast Reconstr Surg 1979;63:570-571. 5. Effendy I, Ossowski B, Happle R. Pincer nail: conservative treatment by attachment of plastic braces. Hautarzt 1993;44: 800-801. 6. Hatoko M, Hiroshi L, Tanaka A, Masamitsu K, Satoshi Y, Katsunori N. Hard-palate mucosal graft in the management of severe pincer-nail deformity. Plast Reconstr Surg 2003;112: 835.