Pincer Nails: Definition and Surgical Treatment

BACKGROUND: There are four main types of ingrown nail. These are distal nail embedding, juvenile (subcutaneous) ingrown nail, hypertrophy of the lateral nail fold (lip), and pincer nail. OBJECTIVE: The etiology of pincer nail may be hereditary or acquired. The mechanism of the most common form, an enlarged base of the distal bony phalanx, is discussed. METHODS: Use of roentgenogram and magnetic resonance imaging highlights exophytes of the base and dorsal hyperostosis of the distal phalanx. RESULTS: Global assessment may lead in mild cases to medical therapy. Usually, however, the lateral matrix horn must be surgically removed or cauterized by phenol. Dermal grafting under the nail matrix provides excellent long-term results.     

交锁髓内钉治疗开放性胫腓骨骨折并发症的原因分析及防治

[目的] 观察交锁髓内钉治疗开放性胫腓骨骨折的并发症的原因及防治措施。[方法]1999年1月～2004年12月用交锁髓内钉治疗开放性胫腓骨骨折120例。男76例，女44例；Gustilo Ⅰ型67例，Ⅱ型47例，Ⅲa型6例；左侧39例，右侧81例；年龄15～78岁，平均34．5岁；Gustilo Ⅰ，Ⅱ型均采用扩髓及静力型固定，Ⅲa型6例均未扩髓。[结果] 120例均得到随访，平均30个月（2个月～5年）。愈合时间12～56周，平均27．4周。术中并发症有髓内钉开口错误3例，术中再骨折4例，小腿软组织损伤4例，锁钉误穿7例，大隐静脉和腓总神经损伤各1例；术后并发症主要有感染8例，膝关节疼痛3例，锁钉断裂4例：主钉断裂1例，骨折迟缓愈合12例，肢体短缩和膝关节内翻各1例。疗效根据Johner-Wruhs标准进行评分，优102例，良16例，差2例，优良率98.3％。[结论] 交锁髓内钉治疗胫腓骨开放性骨折存在一定的并发症，在临床使用中必须引起高度重视；Gustilo Ⅱ以上骨折以不扩髓为宜。     

The cytological and biochemical implications of periungual fibroma.

Periungual fibromas may be acquired lesions or they may be associated with tuberous sclerosis or von Recklinghausen's Disease. Such tumors are comparatively rare benign dermatological entities. Periungual fibromas associated with the posterior nail fold have a potential for inducing deforming nail deformity. Pain resulting from the growth is due to concentration of pressures which may be placed on the nail matrix and contiguous soft tissue structures. This is further complicated by compression developed within the toe box of the shoe. The preferred treatment in symptomatic cases is that of complete surgical excision of the entire lesion. The present study presents such a case, together with histopathological features of this type of growth, with special emphasis on the subcellular features of the neoplasm.     

A simple sterile polypropylene fingernail substitute

Traumatic nail injuries are often observed in clinical practice. Usually the fingernail can be preserved, cleaned and disinfected in order to use it in the reconstructive procedure. However, in some cases the nail can be avulsed and lost or too damaged to be used. In cases when the nail is not available it should be replaced by a substitute in order to protect nail bed and avoid adherences along the proximal nail bed and the nail fold. Furthermore the substitute serves to protect the tender nail bed from painful stimuli during the healing process. We used, as fingernail substitute, a polypropylene sheet in eight patients with fingernail avulsion or disruption. The polypropylene foil was trimmed reproducing the profile of the avulsed fingernail and thinned at the proximal edge to reduce thickness in order to ease the insertion into the nail fold. A small hole was then created in the center of the foil to allow blood drainage. The substitute was usually removed one month after the application. In our clinical experience we had not complications related to the polypropylene device. The new fingernail had good cosmetic appearance in most cases and all the patients reported a good protection of the fingertip during the healing period. The substitute used in this series is sterile, inexpensive and easily available in emergency and elective operatory theater. This polypropylene foil is flexible and can be shaped and adapted to the nail curvature radius. The substitute used in our clinical series protected the nail bed during healing until the growth of the new fingernail and respected our functional expectations.     

AO钢板、矩形髓内钉、带锁髓内钉治疗胫骨骨折的比较

目的探讨胫骨骨折内固定物的临床疗效。方法采用ＡＯ钢板治疗５２例,矩形髓内钉１６例,带锁髓内钉３６例,并进行临床随访分析。结果骨折愈合时间ＡＯ钢板组平均８个月,矩形髓内钉组９个月,带锁髓内钉组６个月。ＡＯ钢板组发生伤口感染３例,延迟感染１例,钢板松动３例;矩形髓内钉组发生畸形愈合２例;带锁髓内钉组发生伤口感染１例,远端锁钉松动１例,膝关痛１例。结论带锁髓内钉为轴性及弹性内固定,内固定坚强,为闭合或半     

Arterial anatomy of the second toe nail bed related to toenail transfer

The aim of this study was to elucidate the exact course of the terminal branches of the plantar digital artery (PDA) to the nail bed of the second toe. Thirteen second toes from seven fresh Korean cadavers were dissected (age range 74–92 years, four men and three women). The terminal segmental branches (TSB) branched off from the PDA at 7.6 ± 0.7 mm proximal to the nail fold. The fibro‐osseous hiatus branch (FHB) branched off from the PDA at 3.3 ± 0.7 mm from the nail fold. They were 3.8 ± 1.0 mm lateral to the paronychium. Diameters of TSB and FHB were 0.8 ± 0.2 mm and 0.7 ± 0.1 mm, respectively. Diameter of PDA was 1.4 ± 0.2 mm. Surgeons should stay at least 4 mm proximal to the nail fold to avoid injury to the terminal branch. We believe that second toenail with minimum amount of soft tissue may be transferred using FHB‐based vascularized toenail flap. Perfusion study and clinical application should be followed. © 2010 Wiley‐Liss, Inc. Microsurgery, 2010.     

Squamous cell carcinoma of the lateral nail fold

The digital nail complex is occasionally involved by squamous cell carcinoma. The published literature has either been indiscriminating of the site of origin of this tumour within the nail complex or has concentrated attention on the nail bed as the site of pathology. Tumours originating in the lateral nail fold can be clearly differentiated from those of the nail bed itself. This study identifies six cases of squamous cell carcinoma arising in the lateral nail fold. While surgical convention remains to amputate the digital tip for squamous cell carcinoma of any part of the nail complex, the dermatological literature identifies that local surgery can be curative for these tumours, when presenting early and without bone involvement, although offering no discussion of reconstruction. Reconstruction is desirable and methods of achieving this following local excision of lateral nail fold tumours are illustrated in this series.     

Advanced nail surgery

Six techniques not yet widely known or used in the dermatologic surgery of the nails are briefly described. Small-to-medium-sized tumours of the proximal nail fold (PNF) can be excised and the defect repaired with advancement or rotation flaps. A superficial biopsy technique of the matrix for the diagnosis of longitudinal brown streaks in the nail, which allows rapid histological diagnosis of the melanocyte focus to be performed, is described here. Because the excision is very shallow and leaves the morphogenetic connective tissue of the matrix intact, the defect heals without scarring. Laterally positioned nail tumours can be excised in the manner of a wide lateral longitudinal nail biopsy. The defect repair is performed with a bipedicled flap from the lateral aspect of the distal phalanx. Malignant tumours of the nail organ often require its complete ablation. These defects can be covered by a full-thickness skin graft, reversed dermal graft, or cross-finger flap. The surgical correction of a split nail is often difficult. The cicatricial tissue of the matrix and PNF have to be excised and the re-attachment of these wounds prevented. The matrix defect has to be excised and sutured or covered with a free matrix graft taken either from the neighbouring area or from the big toe nail.     

A new anatomical repair method for the treatment of ingrown nail: prospective comparison of wedge resection of the matrix and partial matricectomy followed by lateral fold advancement flap

Currently, there are various surgical treatment modalities for ingrowing nail. None of these procedures are perfect to achieve esthetic results with low cost, recurrence, and complication rates. Eighty-seven toenails of 77 patients were operated in our clinic; 49 wedge matrix resections (WMR) and 38 partial matricectomy followed by lateral fold advancement flap (LFAF) were applied. Average follow-up period of the patients was 13 months. The recurrence rates, spicule formation, immobilization periods, and patient satisfaction for cosmetic result and discomforting symptoms were investigated. Nail, distal phalanx bone, soft tissue measurements were performed in the counterlateral healthy toe of 34 patients that we operated due to the unilateral ingrowing nail and 34 randomized individuals with no ingrowing nail by lateral and anteroposterior toe x-rays. There were no significant differences for age, sex, the side of the ingrowing nail, postoperative mobilization period, and the follow-up period between 2 groups that the techniques were applied to. There was no statistically significant difference in WMR (8.1%, 4 toes) and LFAF (none) for the recurrence rate. But there was significant difference between WMR (36.7%, 18 toes) and LFAF (5.2%, 2 toes) for the spicule formation rates (P < 0.05), and there was significant difference between WMR (20.4%, 10 toes) and LFAF (none) for the reoperation (P < 0.03). It was observed that patient satisfaction in cosmetic view was better in patient group treated with LFAF (P < 0.05). Phalanx heads were wider in patient group with ingrowing nail at the results of the measurements (P < 0.01). The fact that granulation and scarred tissues are removed instead of performing the great soft tissue excisions is more correct for both recurrence and cosmetics. Partial matricectomy and LFAF is a good alternative method for the treatment of ingrown nail, with less recurrence rates and cost and better cosmetic results.     

长Gamma钉治疗股骨转子下骨折

目的评价应用长Gamma钉内固定治疗股骨转子下骨折的效果。方法16例股骨转子下骨折采用长Gamma钉内固定,C臂X线机透视下牵引复位,必要时做小切口钢丝环扎或钢缆捆绑复位。结果1例发生延迟愈合,其余病例术后半年随访时骨折均已愈合。肢体功能良好。结论股骨转子下骨折应用长Gamma钉内固定,手术创伤小,骨折愈合率高,符合生物力学的要求。     

Nail grafts for reconstruction

Monkey digits were used experimentally to demonstrate the pathologic anatomy of nail deformities and the results of treatment using full and partial thickness nail matrix grafts. Seventy-five human nail deformities were evaluated and treated. In both the experimental and clinical groups, microscopic hypertrophy of the superficial epithelial elements underlying the deformed nail existed. A follow-up of treatment of nail deformities indicated that nail matrix grafts, both full and partial thickness, are beneficial when the defect involves the sterile matrix and the proximal nail fold.     

扩髓带锁髓内钉治疗下肢长管状骨骨折不愈合

目的探讨扩髓带锁髓内钉治疗下肢长管状骨骨折不愈合的临床疗效。方法采用扩髓带锁髓内钉治疗下肢长管状骨骨折不愈合52例,其中股骨骨折36例,胫骨骨折16例。导致骨折不愈合的主要原因为内固定松动、断裂41例,占78．8％;骨缺损,骨感染、骨折过度牵引等所致11例,占21．2％。按照X线分型标准：肥大型41例,萎缩型11例。本组病例行切开复位,取出原固定物,清除硬化骨、死骨及瘢痕组织,顺行电动或手动扩髓,带锁髓内钉固定,骨折断端间隙及周围植骨。伴膝关节僵硬者,手法和手术相结合松解粘连。根据Judet膝关节活动度疗效评价标准对术后疗效进行评价。结果3例发生浅表感染,其中2例伤口延迟愈合,1例行清创、延期缝合后愈合外,其余49例切口一期愈合。随访时间12—39个月,平均25个月。所有病例均获骨性愈合,愈合时间5—11个月,平均6个月。无深部感染、脂肪栓塞、内固定物松动、断钉、骨折再不愈合等并发症。Judet膝关节活动度疗效评价标准,优良率82．7％。结论扩髓带锁髓内钉治疗下肢长管状骨骨折不愈合是一种有效方法。     

How far does an ingrown toenail enlarge?

Bizarre hypertrophy of the right great toe presented in a 50-year-old woman with an ingrown nail, as well as mild hypertrophy of the left great toe. A fingerlike overgrowth was thought to be a reactive change resulting from repetitive formation of granulation from the histopathological analysis.     

甲沟重建术治疗嵌甲症

嵌甲症作为一种常见病，虽然国内外有多种治疗方法报告，但其复发率可达７３％ ；为了降低嵌甲症治疗后的复发率。自１９９３ 年以来，我们采用了一种病灶切除，利用一侧甲襞推进皮瓣重建甲沟的新方法。结果：治愈率达９５ ．５％ ，重建甲沟形态良好，效果较满意。结论：嵌甲症发生的病理解剖基础是病变甲沟处甲床向甲襞上皮移行中断，炎性肉芽过度充填，局灶性瘢痕形成等，致使甲床向趾骨反折，过度生长，这是造成一般治疗容易复发的根本原因。通过临床实践，我们认为，甲沟重建术是针对这一病理改变所进行的手术设计，确实可靠有效，值得推广。     

手部外伤性异物的治疗体会

目的探讨手部外伤性异物取出术中易忽略的几个问题。方法 10年来对126例手部外伤性异物患者进行了异物取出术。术前、术后均行X线检查,部分患者术前行B超检查。术后随访时间为1~8个月。结果 65例甲下异物患者中,18例行拔甲后,新生指甲欠平整,外形欠佳;47例采用了指甲部分切除,术后指甲生长良好。1例鱼刺伤异物取出(2枚)术后X线复查,仍可见1枚异物残留。1例患者长期(2年以上)针状异物存留,致生锈,取出时断裂。15例仙人掌刺伤异物患者,取出术后有5例局部仍有红肿症状。2例火药爆炸伤患者中,有1例术后经X线复查仍有部分异物残留并导致局部感染。结论甲下异物取出时应尽量避免拔甲,以免甲床长期暴露而变得毛糙,造成指甲畸形;金属异物存留时间较长时间者,取出时应尽可能与周围软组织同时切除,避免异物断裂;对于仙人掌刺存留患者,术中应扩大切除范围;火药爆炸伤应清创彻底。     

Use of a bilobed flap for the treatment of mucous cysts

INTRODUCTION: In the case of mucous cysts with attenuated skin, the authors suggest radical excision of the cyst together with the overlying skin. The skin defect is repaired with a bilobed flap whose donor site is left to heal by secondary intention. This surgical procedure also allows exploration of other areas of mucoid degeneration and repair of the proximal nail fold when necessary. METHOD: Twenty-six patients with an average age of 59 years (27 cysts), were operated with this procedure. Nail bed deformities were present in 55% of the cases. The cyst and the overlying skin were radically excised in conjunction with a dorsal capsulectomy; the use of the bilobed flap made the dissection easier, and flap translation allowed cover of the capsulectomy area and simultaneous repair of the nail fold in eight cases. RESULTS: Patients were reviewed with an average follow-up of 13.7 months. Seventy percent of the patients had no pain, and in 85% of the cases there was no loss of motion. Cosmetic appearance was satisfactory, and nail bed deformities disappeared or clearly subsided in 86% of the cases. One patient developed recurrence. DISCUSSION: Many surgical procedures have been described for mucous cysts treatment. This simple procedure allows radical excision of the cyst and the attenuated skin with low risk for the germinal matrix, precise location of cyst origin, repair of the nail fold and good skin cover in the capsulectomy area.     

股骨转子间骨折治疗方法的研究

目的：比较多种治疗股骨转子间骨折方法各自的优缺点及最佳适应证，从而找出一种最佳的治疗方案。方法：从1991—2001年共收治病例140例，采用瑞士动力髋螺钉(Richard钉)、单臂外固定支架、麦氏鹅头钉、AO角度钢板内固定治疗及骨牵引保守治疗股骨转子间骨折，从中分析出治疗效果的优劣及并发症发生率的多少。结果：Richard钉固定最稳定，承载最大，治疗优良率最高，发生的并发症最少；其次是外固定支架，角度钢板及麦氏鹅头钉。结论：保守牵引治疗股骨转子间骨折经济、安全、简单，但长期卧床易导致并发症且易发生髋内翻，治疗优良率低。对于采用内固定治疗的患者，应首选动力髋螺钉。对于不能忍耐较大手术的患者，应尽可能应用单臂外固定支架。少数用Richard钉及多功能支架难于固定的患者，可采用AO角度钢板固定。而麦氏鹅头钉因其结构不够合理，固定强度不足，术后并发症多，应放弃使用。     

Implantatentfernung nach intramedull?ren Osteosynthesen

We present a literature review about implant removal after intramedullary stabilization of femoral or tibial shaft fractures, upper extremity fractures, and pediatric fractures. A special focus is the difficult implant removal. Implant removal of nails gets difficult when implants are bent or broken. Other difficulties include broken interfaces between nail and removal instrument or when bone ingrowth hinders extraction. A special difficulty is posed by broken solid nails. Implant failure shows typical failure patterns regarding the location of the fatigue fracture. Based on well-documented clinical cases, we describe in detail surgical techniques as well as tips and tricks which help in the difficult circumstances of bent or broken implants in proximal, midshaft, or distal nail segments for a large variety of implants (solid, cannulated, slotted). We also describe an elegant technique for the safe removal of an infected cemented arthrodesis nail. The time required to perform a nail removal can easily exceed the planned amount. Nail removal can result in significant complications like soft tissue damage, fractures, infections, and other problems. Not only because of these problems, the decision on whether or not to remove the nail should be made with great care. Therefore, good communication with the patient and thorough information about risks and benefits are essential.     

手术治疗漂浮膝损伤33例

目的探讨手术治疗漂浮膝损伤的方法和疗效。方法对33例漂浮膝损伤的患者,根据骨折部位、骨折类型及软组织损伤情况,使用股骨加压钢板-胫骨外固定架固定6例,股骨交锁髓内钉-胫骨外固定架固定10例,股骨交锁髓内钉-胫骨交锁髓内钉固定15例,股骨交锁髓内钉-胫骨髁钢板内固定2例。结果3例失访,30例经1～5年随访,平均2年9个月,优良率86.7%。结论早期手术治疗有利于严重多发伤的治疗和关节功能的恢复,手术方法应根据骨折部位、类型及软组织损伤情况,采用合适的方法。     

Management of fingernail deformities after thermal injury

Fingernail deformities after thermal injury can be very disfiguring and troublesome. The fingernails may be discoloured, cleft or vertically deviated. From the pathophysiology of the nail growth in general, the specific features of the nail deformities after deep burn can be deduced, as can guidelines for the treatment. Over a two-year period, 153 patients with burned hands were treated in the Groningen Burn Centre. Seven of these patients developed abnormal quality and growth pattern of the fingernails. In two patients an effort was made to correct the deformity by incising the dorsal skin at the base of the nail fold, reflecting the nail fold and covering the acquired defect with a full thickness skin graft. Although the patients were satisfied with the results achieved, one year after the operation little or no improvement in the nail growth was found. A cautious policy should be followed in correcting these deformities, since dislocation of the eponychium together with damage to the nail matrix and the nail bed play a complex role in the process of deformation.