Hook Nail Deformity Research Articles

V Advancement Flap for Fingertip Injury Preventing Necrosis and Hook Nail Deformity

Objectives: V-Y advancement flap has been a reliable method to reconstruct fingertip defect, since described by Tranquilli-Leali originally in 1935 and popularized by Atasoy later in 1970. But flap necrosis and hook nail deformity due to suture line tension have been pointed out as relatively common complications in V-Y advancement flap for fingertip reconstruction. Concern about this problems, several authors have been described a modification of this technique. The aim of this study was to describe our modification of V advancement flap based on V-Y concept and to review the outcome of this procedure for fingertip amputation in 28 patients. Materials and Methods: This study was conducted from January 2006 to February 2014 and involved 28 consecutive patients (20 men and 8 women; 30 fingertip amputations) with fingertip injury that were treated operatively with the same procedure. All patients with a fingertip defect of more than 1.0 cm2 in area from the tip to lunula were included in this study. The causes of injuries were crushing with or without avulsion in 21, amputation with sharp laceration in 8, and human bite in 1. Twenty-seven injuries were transverse or dorsal oblique type and 3 were mild volar oblique type. According to Allen’s classification, 18 cases were type 2, 11 were type 3, and 1 was type 1. To allow for a tension-free closure, the proximal incision was left unclosed to heal by secondary intension. In addition, the distal nail bed was supported and maintained eversion against base of the flap with a minimal number of horizontal mattress sutures, and there was no suture crossing over the top to prevent hook nail deformity. Postoperatively, dressing changes were performed once daily for 3 or 4 weeks until reepithelialization was observed. Results: The mean age of the patients was 43.6 years (range, 24-65 years). The average follow-up periods was 15 months (range, 12-37 months). All patients underwent objective and subjective assessment at 6 and 12 months routinely and at final follow-up. At final follow-up, all flap healed uneventfully. In objective evaluation with Semmes-Weinstein monofilaments test, 24 cases recognized the 2.83 monofilament (0.07 g), 6 cases recognized the 3.61 monofilament (0.4 g). In static 2-point discrimination test, the mean values were 4.61 mm in injured finger and 4.00 mm in contralateral finger. None of the patients developed a noticeable hook nail deformity. None of the patients complained of hypersensitive digit. However, 3 patients had some residual short nails and 2 patients had mild nail ridges. Patients’ subject rating of the outcome was recorded: “excellent,” “good,” “fair,” and “poor.” Excellent or good results were achieved in 28 cases. Two cases had fair results and none of the patients had a poor result. Conclusions: This modified V advancement flap technique, when properly designed and executed, can minimize morbidity and successfully results in good wound healing without necrosis and hook nail deformity for fingertip injury.

Transfer of phalangeal flap from the big toe for treatment of hook nail deformity

Objective To introduce the methods of using phalangeal flap from the big toe to repair hook nail deformity of the finger. Methods Scar tissue of the stump along with the nail was removed first. The distal phalangeal flap from the big toe was transferred to the stump. The bone flap was used to repair the missing distal phalanx, while the hook-shaped nail bed was lifted and tiled over the bone flap. The skin and subcutaneous tissue of the tissue flap covered the soft tissue defects of the finger. Results The transplanted tissues survived uneventfully in all 3 cases. Follow-up evaluations after more than two years showed significant improvement in the shape of the distal finger. There was no need for secondary plastic surgery. The nail was 1.0, 2.5 and 3.0 mm shorter than normal, respectively, in these three cases. Two-point discrimination of the pulp was 8 to 12 mm. Conclusion Phalangeal flap transfer from the big toe is an effective method to treat hook nail deformity of the finger. Key words: Nails; Surgical flaps; Hook nail deformity

Repair of skin and soft tissue defects at distal end of finger with serrated flap with digital proper artery and nerve pedicle combined with bilaterally pedicled V-Y advancement flap of the injured finger

To investigate the therapeutic effects of repair of skin and soft tissue defects at distal end of finger with serrated flap with digital proper artery and nerve pedicle combined with bilaterally pedicled V-Y advancement flap of the injured finger. Thirteen patients with skin and soft tissue defects at distal end of 13 fingers were hospitalized from September 2013 to January 2015. After debridement, the wound area of finger ranged from 1.2 cm × 0.8 cm to 1.8 cm × 1.5 cm. Serrated flap with digital proper artery and nerve pedicle combined with bilaterally pedicled V-Y advancement flap of the injured finger were used to repair the defect. The flaps were interruptedly sutured. The areas of bilaterally pedicled V-Y advancement flap and serrated flap with digital proper artery and nerve pedicle ranged from 0.52 to 1.11 and 2.60 to 5.23 cm(2,) respectively. All flaps of 13 patients survived completely. The patients were followed up for 6 to 24 months. The color and texture of the flaps were good. After reconstruction, the finger tips were in round in shape. The appearance of the fingers was consistent with that of the normal fingers, and joint motility was normal. No hook-nail deformity or knuckle dysfunction was found. Sensation of the flaps was estimated as S4, and the distance of two-point discrimination ranged from 2 to 3 mm. The recovery of the joint motion function of the fingers was excellent. Serrated flap with digital proper artery and nerve pedicle, combined with bilaterally pedicled V-Y advancement flap from the injured finger can repair the skin and soft tissue defects at distal end of finger with reliable blood supply and simple operative technic. It also could avoid the formation of deformity subsequent to a linear scar, and a satisfactory appearance with good function could be obtained.

The outcomes of digital tip amputation replacement as a composite graft in a paediatric population.

Limited studies exist on the outcome of replacing an amputated fingertip as a composite graft. We report the outcomes and predictors for composite graft survival along with the long-term morbidity. A retrospective review of all patients <16 years who underwent composite graft replacement of an amputated fingertip was performed. Long-term morbidity was evaluated through a standardized parental questionnaire. A total of 120 patients were identified, of whom 97 were eligible for inclusion. Parental questionnaires were completed for 42 (43%) patients. There was a 10% complete and 34% partial graft survival rate. Patients aged ⩽4 were significantly more likely to have complete graft take than those >4. Of the patients, 17% developed post-operative complications; 48% of patients reported a hook-nail deformity and 17% reported cold intolerance. Only 5% of patients reported any functional difficulties long term. The rate of complete composite graft survival in a paediatric population is low, although the long-term function of these patients is good. 3.

Innervated Digital Artery Perforator Propeller Flap for Reconstruction of Lateral Oblique Fingertip Defects

To report our experience with the use of a digital artery perforator propeller flap based on a constant distal perforator in the middle phalanx for resurfacing of lateral oblique fingertip amputations. Twelve fingertips in 10 patients underwent reconstruction, with a mean follow-up of 8 months (range, 8-12 mo). The size of the flaps ranged from 2.5 × 1.5 cm to 3.0 × 2.0 cm. All flaps survived entirely and restored a rounded fingertip contour. Mean static 2-point discrimination was 5 mm (range, 4-6 mm). With the exception of 1 patient with an amputation at the distal interphalangeal joint, the distal interphalangeal joint was preserved in all patients and had 30° to 60° of motion at final follow-up. No patients complained of cold intolerance or residual joint contracture. No hooked nail deformity occurred in patients who had remaining nailbed. The digital artery perforator propeller flap is particularly suited to coverage of a lateral oblique fingertip defect, because only a 90° rotation is required when inset, and the bulk of the flap serves to restore the rounded contour of the fingertip. The skin over the entire dorsal surface of the middle phalanx can be elevated as a flap, providing adequate tissue to resurface the defect and restore a rounded contour to the fingertip. Therapeutic IV.

An algorithmic approach to posttraumatic nail deformities based on anatomical classification

Most of the clinical series on posttraumatic nail deformities (PTNDs) address an individual deformity and its correction. The aim of the study was to classify PTND on the basis of its anatomical defect, devise the reconstructive modality and propose an algorithmic approach to PTND. We have also analysed our results of surgical correction and compared the data with the published literature. A 5-year retrospective study of 45 patients with PTND was conducted. The deformities were classified into three groups: intact nail bed, partially amputated nail bed and completely amputated nail bed on the basis of the remnant nail bed. PTNDs with intact nail bed were present in 78%, with partially amputated nail bed in 16% and with completely amputated nail bed in 7% of the patients. Deformities in intact nail bed group were nonadherence (33%), ridged nail (31%), split nail (9%) and nail horn (4%). All patients with partially amputated nail bed presented with hooked nail deformity. A satisfactory result was seen in 87% of nonadherence, 71% of ridged nail, 50% of split nail and 57% of hooked nail. None of the patients with nail horn and absent nail showed a satisfactory result. PTND with intact nail bed are consistently benefitted when the option is only split-thickness sterile matrix (STSM) grafting. Appreciable correction of hooked nail deformity can be achieved by the reconstruction of lost components. In our opinion, there is no role of split-thickness germinal matrix (STGM) and STSM graft transfer in total nail reconstruction. III.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

Bilateral digital neurovascular advancement flap to repair fingertip defects

Objective To investigate the clinical effects of bilateral digital neurovascular advancement flap for repair of soft tissue defects of the fingertip.Methods From January 2010 to October 2011,9 cases of fingertip defects were treated with bilateral digital neurovascular advancement flap from the same finger.The defect sizes ranged from 2.0 cm× 1.8 cm to 1.5 cm × 1.5 cm.Results All 9 flaps survived after the operation.These cases were follow-up for 14 to 20 months,16 months on average.The flaps had good appearance and fingertips were full.There was no hooked nail deformity and tenderness of the scar in the pulp.Two-point discrimination was 3 to 5 mm.Sweating was normal.The function of finger motion returned to 0° to 60°.According to the upper limb function assessment criteria issued by the Chinese Hand Surgery Society,the results of the 9 cases were graded as excellent.Conclusion Transfer of bilateral digital neurovascular advancement flap for reconstruction of fingertip defect is a simple and ideal method for reconstruction of thumb or finger tip defects with satisfactory clinical results. Key words: Finger injuries; Surgical flaps; Repair

Innervated Digital Artery Perforator Flap

To describe a technique for covering defects of the fingertips: the innervated digital artery perforator (IDAP) flap. A total of 17 patients were treated with an IDAP flap. The size of the flaps varied between 2 ×1 cm and 3.5 × 2 cm. Postoperative evaluation of the patients consisted of the Semmes-Weinstein Monofilament test, static 2-point discrimination, patient satisfaction, extension loss, and an investigation into complications. All IDAP flaps survived completely, and no patients required secondary interventions. The mean follow-up period was 7 months (range, 6-10 mo). The Semmes-Weinstein monofilament test results ranged from 3.22 to 3.84. The static 2-point discrimination in the flaps ranged from 2 mm to 4 mm (mean, 3.4 mm) compared with a range of 2 mm to 3 mm (mean, 2.7 mm) on the contralateral hand. There were no joint contractures in the reconstructed fingertips, although 2 patients developed mild hook nail deformity. One patient experienced mild cold intolerance, and 1 patient exhibited mild postoperative hypersensitivity. The advantages of the IDAP flap include minimally invasive surgery; a reliable, versatile flap; and the ease of the technique for different-sized fingertip defect reconstructions with few complications. The IDAP flap may be useful in fingertip amputations when the amputated part is not suitable for replantation. Therapeutic IV.

Fingertip Reconstruction Using Free Toe Tissue Transfer Without Venous Anastomosis

BackgroundThis study was designed to introduce the feasibility of toe tissue transfer without venous outflow for fingertip reconstruction.MethodsFive cases of fingertip defects were treated successfully with this method. Four cases were traumatic fingertip defects, and one case was a hook-nail deformity. The lateral pulp of a great toe or medioinferior portion of a second toe was used as the donor site. An arterial pedicle was dissected only within the digit and anastomosis was performed within 2 cm around the defect margin. The digital nerve was repaired simultaneously. No additional dissection of the dorsal or volar pulp vein was performed in either the donor or recipient sites. Other surgical procedures were performed following conventional techniques. Postoperative venous congestion was monitored with pulp temperature, color, and degree of tissue oxygen saturation. Venous congestion was decompressed with a needle-puncture method intermittently, but did not require continuous external bleeding for salvage.ResultsVenous congestion was observed in all the flaps, but improved within 3 or 4 days postoperatively. The flap size was from 1.5×1.5 cm2 to 2.0×3.0 cm2. The mean surgical time was 2 hours and 20 minutes. A needle puncture was carried out every 2 hours during the first postoperative day, and then every 4 hours thereafter. The amount of blood loss during each puncture procedure was less than 0.2 mL. In the long-term follow-up, no flap atrophy was observed.ConclusionsWhen used properly, the free toe tissue transfer without venous anastomosis method can be a treatment option for small defects on the fingertip area.

Replantation of Fingertip Amputation by Palmar Pocket Method in Children

Sir: The success of replantation for fingertip amputation is required from a cosmetic perspective. Common procedures for replantation have included microsurgery and composite grafting. Fingertip amputations in children are difficult to treat by microsurgical replantation. In 1979, Brent1 reported a new replantation method for amputated distal phalangeal parts of fingers without vascular anastomosis by using a subcutaneous pocket. Starting in 1996, we modified this method and used a palmar pocket for fingertip amputation in 10 children when vascular anastomosis was not feasible. The patients are summarized in Table 1.Table 1: Summary of CasesFractured bone segments were fixed with Kirschner wires, and the amputated part was reattached to the amputation stump without vascular anastomosis. The amputated part was deepithelialized to the middermal layer using a scalpel after reattaching it to the digit. A 1.5-cm transverse incision was performed in the ipsilateral palm and the subcutaneous layer was undermined bluntly to make a pocket. The reattached part was inserted into the pocket and sutured to the palmar skin to prevent the inserted digit from pulling out. After approximately 2 weeks, the replanted part was removed carefully from the pocket, and some active bleeding was noted from the replanted part. The palmar skin was then sutured. Epithelialization was complete at approximately 2 weeks after the second operation, and thereafter the replanted part gradually became stable (Fig. 1).Fig. 1.: (Above, left) Preoperative dorsal view of the injured finger. (Above, right) The reattached finger in the palmar pocket. (Below, left) Dorsal view of the replanted finger 7 months after surgery. (Below, right) Palmar view of the replanted finger 7 months after surgery.All patients recovered completely. A hooked nail deformity did not occur. There were no cases of severe flexion contracture, infection, or pulling out from the pocket. Inadvertent injury to the digital nerves and arteries traversing the palm did not occur when the pocket was made. When microsurgical treatment is not feasible for fingertip amputation, a composite graft is usually used for restoring the length of the finger; however, this method does not have a good success rate.2 The composite graft is sustained by plasma imbibition until revascularization by means of the amputation stump. Proximal to the center of subzone I3 (Fig. 2), the amputated part is too large for adequate extra blood supply for survival to be provided from the amputation stump. With the pocketing method, the deepithelialized composite piece was inserted into a subcutaneous pocket, which provided more blood. We speculated that because the buried fingers were kept implanted for approximately 2 weeks, improved survival in the replanted fingertips may well have resulted from revascularization by means of the exposed dermal elements in conjunction with revascularization by means of the proximal digital segment. As a pocket site, Brent chose the contralateral chest, whereas other authors4,5 chose the abdomen. Originally, we used pockets in the chest or abdomen, but most patients were anxious about pulling out the pocketed finger, and it was particularly difficult for children to keep the position during a long pocketing period. To avoid these problems, we chose the ipsilateral palm as a pocket site. In conclusion, the palmar pocket method is a simple and reliable operation for fingertip amputation when microsurgery is difficult and composite graft is not reliable and is more comfortable for children than pocketing in the chest or abdomen.Fig. 2.: Subzones of the distal part of the finger classified by Ishikawa.Jun Arata, M.D. Department of Plastic and Reconstructive Surgery Kyoto Medical Center Hospital Fushimiku, Kyoto, Japan Kozo Ishikawa, M.D. Department of Plastic and Reconstructive Surgery Otsu Red Cross Hospital Nagara, Otsu, Japan Haruo Soeda, M.D. Department of Orthopedic Surgery Kyowa Hospital Fushimiku, Kyoto, Japan DISCLOSURE 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.

The outcome of direct-flow neurovascular island flaps in pulp defects

In this study we aimed to evaluate the results of the direct-flow neurovascular island flap (NIF) transfers in pulp defects. We reviewed the records of 96 patients with 115 NIF transfers performed for pulp defect reconstruction. The injury mechanism was crush type injury in 70 patients (72.9%). Ninety-three patients (97%) were emergency cases. Pulp reconstruction was performed by means of pedicled island flap transfer. The results were evaluated with proximal interphalangeal joint range of motion, the Semmes Weinstein monofilament test, static two-point discrimination and cold intolerance assessments. The relations between the injury mechanism, patient satisfaction, cold intolerance and scar problems were analyzed. Also, the association between skin grafting and hook nail deformity was investigated. The level of significance was set at p<0.05. All flaps survived. The mean follow-up time was 41±20.3 (range: 12-108) months. We observed proximal interphalangeal joint flexion contracture in 11 (9.5%) cases. In seven of these, the limitation was less than 10 degrees. Hook nail deformity was seen in 8 fingers (7%). Cold intolerance was found in 16 (17%) cases. Semmes Weinstein monofilament and static-two point discrimination tests of flaps revealed satisfactory results. There was no relation between the injury mechanism and cold intolerance, patient satisfaction and scar problems (p>0.05). Among patients, 91.7% were satisfied with their results. The transfer of direct-flow island flaps, from the same finger, causes minimal morbidity on the donor site and appears to be a safe method, providing satisfactory functional and aesthetic results in the reconstruction of pulp defects.

Homodigital antegrade — Flow neurovascular pedicle flap

Fingertip amputation injuries require an emergency reconstruction. There are a lot of techniques of reconstruction. Its goals are to cover the terminal phalanx, providing good padding, preserving useful sensation, preventing hook nail deformity as well as the morbidity of the donor site. The approach to the choice of the surgical reconstruction procedure depends both on the extent and on the type of the distal amputation. The homodigital antegrade-flow neurovascular pedicle flap is reliable. It provides adequate protective and functional cover to the lost fingertip.

Homodigital Antegrade-Flow Neurovascular Pedicle Flaps for Sensate Reconstruction of Fingertip Amputation Injuries

Fingertip amputations through the distal 50% of the nail matrix usually create a finger that is best served by maintaining length. When the amputation is more proximal than this, revision with ablation of the small residual nail unit may provide greater overall patient satisfaction. When amputations in the distal 50% of the nail matrix are transverse or short oblique in orientation, a flap of some kind is needed to restore the contact surface of the pulp. Many alternative reconstructive strategies are possible but have inherent limitations that detract from the quality of the final result. Inadequate padding, lack of sensibility, excessive tension, hook nail deformity, poor durability, and donor site morbidity are but some of the considerations. Although not a panacea for all distal fingertip amputations, the antegrade-flow homodigital neurovascular pedicle flap offers a good ratio of advantages to disadvantages. As with all flaps, knowledge and execution of the details largely determine the outcome.

Nonmicrosurgical Replantation Using a Subcutaneous Pocket for Salvage of the Amputated Fingertip

The pocket principle suggested by Brent in 1979 is an alternative method for use when microsurgical replantation is not feasible. The application and the amputation level for which the method is available, however, have not been well examined. Between 1999 and 2003 we treated 6 patients (7 fingers) by nonmicrosurgical replantation using a subcutaneous pocket (the Brent technique). All patients had sustained complete fingertip amputations across or proximal to the lunula in digits other than the thumb. In every case the amputation was a crush or avulsion-type injury and microsurgical replantation was not feasible; however, cosmetic symmetry was desired strongly by the patient. Of the 7 fingers only one survived completely but became atrophic after 4 months. One finger developed necrosis involving less than half of the replant but a hooked nail deformity developed. Two fingers developed partial necrosis involving more than half of the replant but both fingers were missing the fingernail and the cosmetic results were not acceptable. Three fingers developed total necrosis. In addition a slight flexion contracture not improved with therapy in the digits was noted in 4 patients. The Brent technique should be performed scrupulously for fingertip amputation across or proximal to the lunula because of the poor survival rate and the possibility of contracture in the digits or other proximal joints.

Antenna procedure for the correction of hook nail deformity

A total of seven antenna procedures for hooknail deformity were performed between 1990 and 2000. At a mean follow-up of 3 years 4 months there were no major complications, all patients had an improvement in their deformity (subjectively and objectively) and were pleased with their results. Some residual deformity remained in all cases including shortening of the nail, contour defect of the pulp and flattening or residual curvature of the nail.

Prevention of the parrot beak deformity in fingertip injuries.

The nail is supported by the dorsal tuft of the terminal phalanx. Following distal fingertip trauma, varying amounts of nail support may be lost resulting in the nail curving palmarwards. This curvature is dependent upon the degree of bony loss, the amount of remaining nail bed and the degree of scar contracture at the hyponychial-pulp interface. The parrot beak or hooked nail deformity is most commonly caused by tight closure of a fingertip amputation and excessive palmar tension at the hyponychial-pulp suture line. A simple technique using a hypodermic needle, that eliminates tension from the suture line at the fingertip pulp-hyponychial interface and prevents hooked nail deformity is described. This allows healing to take place without any palmarwards pull of the scar and a subsequent parrot beak deformity.

Hook-nail deformity: Surgical treatment with a homodigital advancement flap

Sixteen patients presenting 18 hook-nail deformities have been treated by the advancement of a homodigital island flap. With an average follow-up of 31 months; Results were considered good or excellent in seven cases, fair in seven and poor in four. Six cases, although improved, had a marked recurrence of the deformity, six had a partial recurrence and six had almost no recurrence. Patient satisfaction was limited as the finger still had a short nail and a square shape.

Treatment and prevention of “hook nail” deformity with anatomic correlation

The hook nail deformity is a relatively common complication after fingertip amputation. It can be corrected or prevented with a carefully performed surgical procedure. The nail plate is removed. The redundant nail bed that is folded over the tip of the terminal phalanx is carefully removed with an additional 2 mm that is supported by the terminal phalanx so that wound healing will not draw the nail bed over the tip of the phalanx again. The fingertip is then resurfaced by a V-Y advancement flap, with precautions taken to avoid all tension in the flap.

Hook nail deformity repaired using a composite toe graft.

The hook nail deformity is caused by loss of fingertip bone and soft tissue. Healing can result in a volarly displaced distal nailbed and a tight tip with inadequate padding and a poor cosmetic appearance. A composite graft from the second toe placed beneath the released nailbed gives good support and improved pulp substance. The technique of the composite toe graft has been performed in nine patients. All grafts were 100 percent viable, but one patient required a second graft for additional tip bulk. There has been no donor-site morbidity in the follow-up of 1 month to 2 years.