Subungual melanoma: An important tip

Acral lentiginous melanoma is rare, representing approximately 1% of malignant melanomas. Overall 5 year survival is disproportionately poor (25-51%) compared to other histological subtypes. This has been attributed to diagnostic delay resulting in more advanced presentation. Subungual presentation in the fingers is uncommon, reported in 1-13% of all acral lentiginous melanomas. We report a unique and diagnostically challenging case. Contrary to previously reported examples in the literature, the actual neoplastic pathology was detected in the less pigmented finger tip skin rather than the deeply pigmented nail bed germinal and sterile matrix that showed no evidence of malignancy. We therefore advocate that in cases where skin surrounding the nail is involved, this surrounding skin should also be biopsied, even if it is less pigmented than the primary lesion.     

甲母痣恶变易感性与谷胱苷肽S转移酶M1、谷胱苷肽S转移酶T1基因缺失的关系

目的 探讨谷胱苷肽S转移酶M1(GSTM1)、谷胱苷肽S转移酶T1(GSTT1)基因缺失与甲母痣恶变之间的关系.方法 采用聚合酶链反应(PCR)技术检测77例甲母痣恶变患者和107例甲母痣患者中GSTM1、GSTT1基因缺失的频率.结果 病例组GSTM1基因缺失的频率为58.4%,显著高于对照组的缺失频率42.1%(x2=4.811,P＜0.05),危险度分析得出OR=1.938,95%CI为1.070～3.509;病例组GSTT1基因缺失的频率为57.1%,接近对照组50.5%的水平(x2=0.802,P＞0.05).联合分析表明两基因在甲母痣恶变发生中具有协同作用.结论 GSTM1基因缺失或GSTM1、GSTT1基因联合缺失在甲母痣恶变患者中发生频率增高,能增加甲母痣恶变的易感性.     

Onychomatricoma: A Rare and Potentially Underreported Tumor of the Nail Matrix

Onychomatricoma is a rare benign neoplasm of the nail matrix first described by Baran and Kint in 1992. Fewer than 80 cases of onychomatricoma have been described in the literature, 15 of which were initially misdiagnosed and treated as onychomycosis. We present the case of a 66-year-old male with thickening and linear xanthonychia of the hallux nail plate secondary to an onychomatricoma misdiagnosed as onychomycosis. Following biopsy for histopathologic analysis, the lesion and proximal nail matrix were surgically excised. At 12 months post-excision, the patient remains asymptomatic without evidence of recurrence. The purpose of the present case report is to make foot and ankle surgeons more cognizant of the pathology, highlight the nonspecific clinical and radiologic findings, and emphasize the importance of interdisciplinary communication for an accurate clinicopathologic correlation and diagnosis of the lesion. Although rare, onychomatricoma should be considered in the differential diagnosis for patients presenting with onychomycosis failing to respond to antimycologic treatment. The clinical index of suspicion for onychomatricoma should increase when only a singular dystrophic nail is involved. Following diagnostic confirmation by histopathology, complete surgical excision is the treatment of choice.     

The microvasculature of the nail bed, nail matrix, and nail fold of a normal human fingertip

The organization of the microvasculature of the dorsal human fingertip based on a vascular corrosion cast was examined using a stereoscopic microscope. The variations of the superficial capillary network of the 3 specialized areas of skin of the dorsal fingertip (the nail bed, the nail matrix, and the nail fold) are described. In the nail bed numerous capillary loops were observed arising from a deeper regular arrangement of sagittally aligned, parallel rows of vessels. The size and direction of inclination of the capillary loops varied, getting longer and more inclined to the nail bed distally, with the longest capillary loops seen at the hyponychium. There were no capillary loops at the nail matrix region, but there was a single, layered, rectangular plexus of capillaries in the plane of the nail matrix. This extended distally to sagittally stretched coils of vessels that straightened out as the nail matrix enters the nail bed region. At the edge of the proximal nail fold the capillary loops looked like fine bristles and were approximately 3 times shorter than those found on the nail bed and hyponychium. This study provides a baseline for future work in understanding the changes in the microvasculature of the dorsal fingertip due to injury or pathology.     

Periungual Basal Cell Carcinoma: Case Report and Literature Review

BACKGROUND Basal cell carcinoma, the most common malignancy in humans, rarely occurs on the nail unit and may be frequently misdiagnosed clinically.
OBJECTIVES To present a case of basal cell carcinoma of the nail unit successfully treated with the mohs technique and to review the literature regarding this unique presentation of this tumor.
MATERIALS AND METHODS: Case report and review of the English literature of nail unit basal cell carcinoma.
RESULTS In addition to the currently described patient, 17 other patients with nail unit basal cell carcinaoma have been reported. The tumor occurred approximately 3 times more often on the fingers then on the toes and had a slight predilection to occur in men. Ulceration, noted in more than one-half of patients, was the most common presentation of nail unit basal cell carcinoma. Mohs micrographic surgery. Often with second intention healing, was successfully employed in 39% of patients.
CONCLUSIONS Basal cell carcinaom infrequently involves the nail unit and often presents as ulceration. Adequate biopsy of the lesion is essential in making a timely diagnosis. Mohs micrographic surgery with second intension healing is an effective treatment that may offer excellent cosmetic and functional results.     

Subungual Schwannoma: A Rare Location

BACKGROUND: Schwannoma is a benign tumor of neural tissue and usually develops in deeper soft tissue. Cutaneous involvement is uncommon, and a subungual location is extremely rare. In fact, it has not been previously reported. OBJECTIVE: To present a case of subungual schwannoma. METHOD: A 49-year-old man had a subungual tumor on his right thumb of 8 years duration. The lesion caused a mild stinging sensation in winter and grew slowly. The tumor was excised using a transungual approach. After closure, the wound was dressed with a trimmed original nail plate. RESULTS: The nail plate grew normally, and there was no recurrence 1 year postoperatively. CONCLUSION: We describe a case of schwannoma that developed in the subungual area of a thumb. Although schwannoma rarely develops in this area, it should be considered in the differential diagnosis of subungual tumor.     

Malignant rhabdoid tumors of the central nervous system. Report of a case

Primitive malignant rhabdoid tumor of the central nervous system are extremely rare. Less than 70 cases are reported in the literature. This tumor grows during the first months of life and prognosis is very poor. We report a case of primitive malignant rhabdoid tumor in a 17-year-old young adult. To our knowledge it is the first such case reported in the literature. We review the clinical feature, the neuradiological and therapeutical aspects.     

Surgical intervention for congenital nail fold hypertrophy

Congenital nail fold hypertrophy of the hallux is an uncommon abnormality affecting the periungual soft tissue of the great toe. It is usually identified at birth or shortly thereafter, and is known to spontaneously resolve in most cases. In this report, we describe the case of a 14-month-old boy presenting with nail fold hypertrophy of both great toes. The completely united skin bridge covering the nail on the right was excised and the nail folds recreated, with debulking of the left hypertrophic nail fold. We propose that management should be conservative in the first instance and that surgery should be reserved for cases in which 1) inflammation is unresponsive to conservative measures, 2) there is a dense condensation of tissue crossing the nail surface, or 3) there is significant hypertrophy persisting past 1 year of age with no signs of resolution.     

Recommendation of use of checklists in tibial intramedullary nail removal: Retrospective study of mechanical complications related to nail removal

BackgroundThe removal of implants such as intramedullary nails is one of the most common operations in orthopedic surgery. The indications for orthopedic implants removal will always remain a subject of conversation and hardly supported by literature. The aim of this study to report injuries of treatment in tibial nail removal and to determine if there are fracture characteristics, patient demographics, or surgical details that may predict a complication.MethodsThis is a retrospective seven-year (2010–2016) study including a total of 389 tibial intramedullary nail removals at the Helsinki University Hospital’s orthopedic unit. Patients with tibial fracture and removal of intramedullary nail were identified from the hospital discharge register and analyzed.ResultsA total of 21 (5,4%) nail removal related mechanical complications (iatrogenic fractures, nerve injuries, failures to remove the nail) were noted. The most common complication was iatrogenic fracture (n = 15, 3,8%). In 6/15 cases the fracture was caused by broken interlocking screws, In 5/15 cases the iatrogenic fracture was caused accidentally by extracting the nail without prior removal of all distal interlocking screws. In one case, new condensed bone had formed around the nail’s distal end and case the forced nail extraction caused a re-fracture in both tibia and fibula.ConclusionNail removal can be a challenging operation which does not always receive the necessary preoperative planning or operative expertise. Iatrogenic fractures were most often caused by inadequate preoperative planning or assuming that a broken interlocking screw tilts during the extraction. We suggest the use of checklists in preoperative planning to avoid fractures caused by broken or undetected interlocking screws.     

两种方式治疗胫骨中下段骨折的疗效比较

目的 比较经皮微创锁定钢板内固定(MIPPO)和交锁髓内钉内固定治疗胫骨中下段骨折的疗效.方法 将90例胫骨中下段骨折患者按治疗方法 不同分为髓内钉组(采用交锁髓内钉内固定治疗,40例)和MIPPO组(采用MIPPO治疗,50例).记录并发症情况和骨折愈合时间.术后1年采用Johner-Wruhs评分和疼痛VAS评分评...     

Localisation inhabituelle pulpaire d’un kyste trichilemmal proliférant

Trichilemmal cyst is a benign tumor, developed from hair follicle, located mainly at the scalp. We report a clinical case of unusual location at the finger pulp confirmed by histology. The main differential diagnosis in this reported case was a whitlow. The origin of this cyst is probably the nail matrix whose keratinization is trichilemmal. Surgical excision biopsy allowed a good clinical outcome.     

A case of pathological fracture associated with chondroblastoma of the first metatarsal: natural development over 3 years

Chondroblastoma of the metatarsal is a very rare condition. To our knowledge fewer than 20 cases have been reported in the world literature. We report a 34-year-old man with chondroblastoma of the first metatarsal. The clinical, radiological and pathological aspects of the tumor are discussed. On pathological examination, there were no typical findings suggestive of benign chondroblastoma such as chicken wire calcification. Therefore, it was difficult to determine whether the eosinophilic matrix observed in the stroma was osteoid or cartilaginous tissue, and differentiation from osteoblastoma was needed. However, the follow-up period of this patient was prolonged, and pain that was possibly due to pathologic fracture had occurred during this period, suggesting that these factors could have promoted fibrosis. The patient was treated by curettage and autologous bone grafting. At 4 years after surgery, there has been no evidence of recurrent tumor.     

Use of the reamer-irrigator-aspirator may reduce tumor dissemination during intramedullary fixation of malignancies

Intramedullary nail fixation is the treatment of choice for impending and pathologic fractures secondary to metastatic cancer; however, this procedure has been shown to cause systemic embolization of intramedullary contents. This article reports the use of the reamer-irrigator-aspirator (RIA) (Synthes, Paoli, Pennsylvania) instead of a standard femoral reamer to decrease tumor intravasation during femoral intramedullary nail fixation for impending or pathologic fractures.Twenty-one consecutive patients indicated for fixation of malignant femoral lesions were treated with intramedullary nail placement. The RIA was used for canal preparation, and solid reamings were collected and submitted for analysis by a single pathologist. The volume of each specimen was recorded, and representative samples were examined histologically to determine their percent tumor content. These data were then used to estimate the volume of tumor retrieved by the RIA in each case. The mean volume of reamings collected by the RIA was 75.0 cc per case (range, 23.4-196.0 cc), and the mean tumor content was 24.8% (range, 1.0%-60.0%). The mean estimated volume of tumor retrieved in each case was 16.7 cc (range, 0.35-36.0 cc). In 2 cases, the tip of the RIA dissociated from the device intraoperatively but was retrieved without adverse consequence to the patient. Use of the RIA in cases of femoral intramedullary nail fixation for pathologic lesions or fractures effectively retrieves variable amounts of intramedullary contents, including tumor. By preventing the systemic dissemination of malignant cells, this technique may reduce the risk of distant metastases.     

A giant subungual exostosis perforating through skin of the toe

Subungual exostosis is typically an uncommon, benign, bony tumor of cartilaginous bone that usually occurs as a solitary, solid lesion under the nail of the first toe or the fingernail. It may be difficult to diagnose subungual exostosis from a clinical presentation and it should be confirmed by radiographic examination. The treatment is surgical excision. It is essential to see normally cancellous bone under the area of excision to ensure that the tumor does not recur. In this article, our goal is to present a subungual exostosis case of the first toe, detailing diagnosis, pathologic findings and surgical management.     

Gangliocytic Paraganglioma: Case Report and Review of the Literature

Gangliocytic paraganglioma is a rare tumor, which occurs nearly exclusively in the second portion of the duodenum. Generally, this tumor has a benign clinical course, although rarely, it may recur or metastasize to regional lymph nodes. Only one case with distant metastasis has been reported. We present a case of duodenal gangliocytic paraganglioma treated first by local resection followed by pylorus-preserving pancreaticoduodenectomy. Examination of the first specimen revealed focal nuclear pleomorphism and mitotic activity, in addition to the presence of three characteristic histologic components: epithelioid, ganglion, and spindle cell. In the subsequent pancreaticoduodenectomy specimen, there was no residual tumor identified in the periampullary area, but metastatic gangliocytic paraganglioma was present in two of seven lymph nodes. This case report confirms the malignant potential of this tumor. We review the published literature on gangliocytic paragangliomas pursuing a malignant course. We conclude that surgical therapy of these neoplasms should not be limited to local resection, as disease recurrence, lymph node involvement, and rarely distant metastasis may occur.     

Removal of a broken intramedullary femoral nail with an unusual pattern of breakage: a case report

To the best of our knowledge, only 3 cases, including the present case, have been reported with a three part broken pattern. However, this is the first case associated with a distal locking screw broken. We report the case of a 31-year-old patient who sustained an open femoral shaft fracture . The fracture was stabilized with a Kuntcher femoral nail. After 7 months of the initial surgery he presented with a three part broken intramedullary nail and the distal locking screw broken. We used a combined technique for the removal of the nail through the nonunion fracture site; we used a pull out technique for the middle fragment and a curved thin hook for the distal fragment. Then we applied bone allograft and stabilized with a cannulated intramedullary femoral nail (Synthes, Oberdorf, Switzerland). After 2 years of follow up the nonunion was consolidated and the patient presented a good clinical outcome. This is of particular interest because it is a unique case and the association with a broken distal locking screw is reported for the first time in this study. A combination of methods through the nonunion site approach and an alternative instrumental is a good method for the removal of a hollow femoral intramedullary nail with this unusual pattern of breakage.     

Application of the palmar pocket method for total nail reconstruction without vascular anastomoses

We present a case of a nail defect, which was reconstructed by free composite nail combined with the palmar pocket method without vascular anastomoses. A 40-year-old man lost his nail of the right middle finger by trauma 1 year ago. A total nail composite graft, composed of germinal and sterile matrices, and proximal nail fold, from which the nail plate was removed, was harvested from the ipsilateral first toe and was grafted on the right middle fingertip. The grafted nail was inserted into the palmar subcutaneous pocket. Fourteen days after the first operation, the grafted part was removed from the pocket, and active bleeding was noted on the sterile matrix. Seven months after the second surgery, the nail had grown and had an almost normal appearance. There was no conspicuous scar at either the recipient or the donor site.     

Surgical options in the management of ingrown toenails in paediatric age group

Background and objectiveThe problem of ingrown toenails is worldwide, affecting all age groups. The aim of this study was to review the different surgical modalities for ingrown toenails in the paediatric age group in a hospital.MethodsWe reviewed case series of 66 children with 89 affected toes, under 16 years of age. The patients were followed up for up to 18 months. The treatment methods practised were: (1) nail avulsion with or without nail matrix ablation using phenol and (2) wedge excision with or without nail matrix ablation using phenol or thermal ablation.ResultsWe found a recurrence rate of 3% for those treated with wedge excision alone compared to 30% when treated with wedge excision and phenol ablation (p = 0.001). Infection rate was also higher for wedge excision with phenol ablation. We achieved cure rate of 97% when using wedge excision alone and 70% when phenol was used for nail matrix ablation.ConclusionWe advocate wedge excision as primary treatment of ingrown toenails in children. We would not recommend phenol ablation of the nail matrix in younger patients as it increases both infection and recurrence rates. The results of nail bed ablation with diathermy appear promising.     

Longitudinal erythronychia: the value of cosmetic alterations in nail findings

A 71-year-old man presented to the authors' clinic for evaluation of a red line under his right thumb. He noticed a red streak develop during the past year. It slowly grew in width and become more prominent in color (Figure 1). It did not cause pain. He delayed presentation because he perceived it to be only a cosmetic issue. Medical history included a metastatic atypical carcinoid tumor to the liver, lung, and the bone diagnosed 9 years ago. He had undergone multiple debulking surgeries and was currently taking octreotide and zoledronic acid. He had not started any new medications in the past 2 years. Review of systems was unremarkable. On physical examination, the right thumb nail was noted to have a red streak that began at the distal matrix. The line ended at the distal nail plate with distal disintegration and subungual hyperkeratosis. A biopsy was performed through the nail plate. The site removed by biopsy included the area in which the erythronychia visibly started, as well as the preceding normal nail matrix. The ventral nail plate was noted to have a groove of thinning, with slight purple discoloration. The nail bed/matrix was red in a linear pattern and no clinically apparent hyperkeratosis was noted. The matrix/bed sample was sent for pathologic evaluation. Notable findings included an acanthotic epidermis with some enlarged nuclei (Figure 2). Mild capillary dilatation was present in papillary dermis. Focal solar elastosis in the distal portion of the nail bed was identified. In situ hybridization for low- and high-risk human papillomavirus was negative. An immunohistochemical study using a panmelanocytic cocktail (HMB45, anti-MART1, anti-tyrosinase) failed to reveal any melanocytic lesion. Perl's iron stain was negative. Metastatic carcinoid or primary squamous cell carcinoma were not identified.     

Nail changes associated with scleroderma: a case report

A case report and literature review on the association of nail changes and scleroderma was presented. The exact etiology of these nail changes seen in scleroderma and of the disease entity itself, has not yet been determined. The current treatment regimen, which is at best supportive, was discussed. Proper treatment of the nail changes depends on a good understanding of what to expect as the disease or condition progresses to its later stages. The extent and severity of the onychodystrophy can be correlated with the duration of the disease. Nonetheless, there are still questions that remain to be answered regarding the nail changes associated with scleroderma. For example, are these nail changes the result of Raynaud's phenomenon and its associated arterial insufficiency, or are they a normal sequelae of the integumentary degeneration so characteristic of scleroderma? Whatever the answer may be, it should be recognized that these changes are a source of clinical concern. Practitioners should take note of this clinical entity and record their findings so that these perplexing questions, as well as many others, may be discussed in the future.