2 Posttraumatic Split Nails
2.1 Patient History Leading to the Specific Problem
A 53-year-old man presents with a chronic splitting of his nail plate. He complained of repetitive trauma to the digit as the split nail caught on clothes (▶Fig. 2.1). He had injured the fingertip and nail bed in a door over a year and a half ago. As the nail grew out from the injury, the split in the nail plate became more apparent and more prominent. No attempt at repairing the nail bed was performed in the local emergency room at the time of his original injury.
2.2 Anatomic Description of the Patient’s Current Status
The patient has an area on the sterile matrix where the nail plate is nonadherent from scar tissue within the nail bed. This also results in splitting of the nail plate. The normal nail originates from the germinal matrix under the eponychial fold. The nail plate grows distally at a rate of about 1 mm/wk. The nail plate remains adherent to the nail bed through a very specific anatomic relationship between the nail bed and the nail plate. A series of undulations in the nail bed allows the nail plate to grow around each one of these tissue peninsulas, which prevents dislodgment of the nail plate (▶Fig. 2.2). In addition, there is an adhesive-like “super glue” called the soul horn between the nail bed and the nail plate that helps the nail plate adhere to the nail bed. Scar tissue that forms between the normal junction of the nail bed and the nail plate prevents the nail plate from adhering and results in a splitting of the nail as it grows distally. The greater the amount of scar tissue, the greater the amount of nonadherence and nail plate disruption. The nail plate that does not adhere to the nail bed is subject to repetitive trauma as it catches on pockets, clothes, and other items.
2.3 Recommended Solution to the Problem
One should first realize that this problem could be prevented by the immediate repair of the nail bed at the initial time of injury. Now, however, the nail bed scar tissue needs to be removed and replaced with a split-thickness sterile matrix graft. Full-thickness grafts are not necessary and can result in donor site morbidity. If the nail bed scar tissue is isolated to a small area of the nail bed, then a split-thickness sterile matrix graft can be taken from the same finger’s nail bed. Larger areas of scar tissue require the great toe to be used as a donor site to obtain a sterile matrix graft.
2.3.1 Recommended Solution to the Problem
• The nail bed scar tissue needs to be removed and replaced with a split-thickness sterile matrix graft.
• A split-thickness sterile matrix graft can be taken from the same finger’s nail bed if the nail bed scar tissue is isolated to a small area.
• Larger areas of scar tissue require the great toe to be used as a donor site to obtain a sterile matrix graft.
• This problem could be prevented by immediate repair of the nail bed at the initial time of injury.
Fig. 2.1 A 37-year-old male with a posttraumatic nail deformity. The nail has a split secondary to scar tissue within the nailbed.
