Hook nail deformity in a child – treatment option with bone graft and thenar flap. Case study with pros and cons

Abstract

Introduction. Hook nail deformity is a common complication following fingertip amputations. Loss of distal bone support and palmar pulp tissue, results in the volar curving of the nailbed, which may cause pain, and aesthetic and functional problems. A few procedures have been described to address nail deformity, including flaps, skin and bone grafts, and microsurgical transfer. Unfortunately, none of the techniques provides reliably good and persistent correction. Case report. An 8-year-old boy sustained amputation of the distal phalanx of the middle finger and underwent surgical closure of the wound. After 4 years, the patient was admitted to our Department due to a deformed hook nail, which was aesthetically distressing. The hook nail was curved volarly and obliquely. The radiographs showed the lack of a significant part of the distal phalanx. Treatment. Surgical reconstruction of deficient distal phalanx was performed. The iliac bone graft, inserted into the distal phalanx, was stabilized with two K wires. A Pedicled flap of full-thickness from the thenar was used to cover skin loss over the fingertip. Pedicle division was performed at around 4 weeks. “K” wires were removed after 4 months. Results. The procedure was well-tolerated by the patient, and no complications occurred. Bone graft provided solid support for the nail bed during healing. Adequate growth and aesthetics of the hook nail were achieved. At 2 years follow-up, slight rotation of the nail was observed, which could have resulted from partial graft resorption and growth of the patient. The patient was satisfied with the treatment. Conclusions. Although perfect restoration of the nail bed length and pulp contour remains unobtainable, our result showed stable correction of the hook nail deformity.