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Abstract:
Onychogryphosis is characterized by
thickening, increase in length and curvature of the nail plate. Commonly
described in great toe nail but no toenail is exempted. However five
fingernail onychogryphosis as in our case has not been previously reported.
Case Report:
Thirty- nine year old male presented
with long thickened and curved nails of all the five fingers of the left
hand (Fig.1) with significant past history of orthopaedic surgery for
displaced compound fracture of both bones of the left forearm. On
examination, the left forearm was wasted and had "claw-hand" deformity with
bilaterally symmetrical radial and ulnar pulses. All the five nails of the
left hand were long, thickened, curved with horizontal ridging on the dorsal
surface and brownish yellow in color. Skin over the left hand and fingers
was thin, shiny, atrophic, with loss of hairs and few hypo-pigmented macules.
Flaccid blisters were present in mid palmar area and palmar aspect of left
hand fingers. All modalities of sensations were lost in the involved hand.
Potassium Hydroxide (KOH) test and fungal culture of nail scrapings were
negative. Examination of the right hand was normal. A diagnosis of
neurogenic five fingernail onychogryphosis was made. Chemical nail matrix
ablation was planned but patient did not comply.
Discussion:
Onychogryphosis is characterized by
thickening, increase in length and curvature of the nail plate. This is
sometimes referred to as a "ram's horn nail" because of the strange shape.
Higashi et al [1]
reported it to be of two types; congenital and acquired. Onset of the
congenital type, which is of autosomal dominant inheritance, occurs at
puberty. The acquired type may be caused by trauma, inflammation of the nail
bed or disorders of the peripheral circulation. [2]
The nails of the great toes are most commonly involved, although, finger
nails may also be affected. [1,3]
The nail becomes thicker, longer, curved, and circular in cross section like
a ram's horn. There are two possible explanations for this deformity: there
may be insufficient matrix under the posterior fold to exert a flattening
effect, or the nail bed may contribute a greater quantity of keratin to the
nail than is normally the case. [3]
In this particular case the presence of bullae on the palm were explained by
repeated trauma of onychogryphotic nails to the anaesthetic skin.
In treating the condition, two problems have to be solved; the nail bed
deformity and the retracted dorsal skin proximal to the nail. Nail bed
deformity can be improved by nail avulsion, removal of the affected nail and
through ablation of the nail matrix, application of the CO2
laser, [4]
removal of the distal tissue bulge of the affected nail, [1]
paring and trimming of the affected nail using nail clippers and a file or
mechanical burr. [3]
The problem of the retracted dorsal skin can be improved by skin grafting or
application of a local flap to the affected digit. [5]
The onychogryphosis of thumb nail has been treated with free vascularised
nail graft from the great toenail. [6]
In this particular case, chemical nail matrix ablation was planned but the
patient did not comply.
 | Fig 1:
Five finger onychogryphosis. |
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References
1.
Higashi N, Matsumura T. The aetiology
of onychogryphosis of the great toenail and of ingrowing nail (in Japan).
Skin Res 1988; 30: 620- 5.
2.
Dawber RPR, Baran R. Onychogryphosis
and hypertrophy. In: Champion RH, Burton JH, Ebling FJG. Editors, Textbook
of Dermatolgy, 5th ed. Oxford: Blackwell Scientific Publications. 1992;
p2523.
3.
Kouskoukis CE, Scher RK.
Onychogryphosis. J Dermatol Surg Oncol 1982; 8: 138- 40.
4. Kaplan I, Labandrar H.
Onychogryphosis treated with the Co2 surgical laser. Br J Plast Surg 1976;
29: 102- 3.
5.
Achauer BM, Welk RA. One stage
reconstruction of the post burn nail fold contracture. Plast Reconstr Surg
1990; 85: 937- 940.
6.
Oka H, Asakage Y, Inagawa K, Moriguchi
T, Hamasaki T. Free vascularised nail grafts for onychogryphosis of
bilateral thumbnails after burn injury. Burns 2002; 28: 273- 275.© 2009 Egyptian Dermatology Online Journal |
