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PubMed1999

"Endonyx" onychomycosis: a new modality of nail invasion by dermatophytes.

Three patients with onychomycosis due to Trichophyton soudanense with an "endonyx" type of nail invasion are presented. Endonyx onychomycosis is clinically characterized by a diffuse milky-white discolouration of the affected nail, in the absence of nail bed hyperkeratosis or onycholysis. Nail plate surface and nail thickness are normal. The pathology shows a contrast between the great number of fungal hyphae visible in the nail plate and the absence of fungal elements in the nail bed. The nail bed does not show inflammatory changes or hyperkeratosis and adheres strictly to the lowermost layers of the nail plate. The hyponychium is normal and does not contain hyphae. The endonyx pattern of nail infection appears to be specific to T. soudanense nail invasion and may possibly reflect the high affinity of T. soudanense to hard keratins.

Aged↗

PubMedDate not supplied

Clinical performance of a new medullary humeral nail: antegrade versus retrograde insertion.

OBJECTIVE: A new intramedullary nail system for humeral shaft fractures is evaluated to determine whether retrograde nailing is as reliable as antegrade nailing. STUDY DESIGN: Prospective multicenter nonrandomized clinical study. PATIENTS: Eighty-four patients with acute humeral shaft fractures were nailed with the new unreamed humeral nail (UHN) system. Fifty-seven nails were introduced retrogradely, and twenty-seven antegradely. Bone healing and functional outcome were the follow-up parameters. RESULTS: The ratio of perioperative complications was equivalent for both groups, but one shaft fracture and three fractures or fissures at the entry point occurred in the group with retrograde nail insertion. Five fractures, all with retrograde nail insertion, needed secondary surgery to achieve bony healing. There was no difference in functional outcome after healing in either group. CONCLUSION: Retrograde nailing of humeral shaft fractures is technically more demanding than antegrade nailing. Fractures or fissures at the insertion point must be avoided by adequate preparation of the entry hole and careful nail insertion. Bone healing problems seem more surgeon-related than approach-related. As in every other procedure, an optimal fracture configuration and high fracture stability must be achieved.

Adolescent↗

PubMed2004

A mechanical study of gap motion in cadaveric femurs using short and long supracondylar nails.

OBJECTIVE: To determine the relative stability achieved in unstable supracondylar femur fractures treated with long (36 cm) and short (20 cm) retrograde intramedullary nails using 1 or 2 proximal locking bolts. We hypothesized that longer nails would reduce fracture site motion compared with short nails and that 2 proximal locking bolts would improve stability compared with 1 proximal locking bolt. DESIGN: Nine pairs of matched human cadaveric femurs were instrumented with 20-cm and 36-cm retrograde intramedullary nails (all 12-mm diameter, Biomet, Warsaw, IN) following reaming to 13 mm. Transverse supracondylar gap (6 mm) osteotomies were created. The femurs were mounted and cyclically tested separately in coronal plane bending and sagittal plane bending on a materials testing system. Fracture site translation was measured using a digital caliper in the respective plane. SETTING: Orthopaedic biomaterials laboratory. RESULTS: With 2 proximal locking bolts, average sagittal translation was 7.2 mm and 1.8 mm, respectively, for the 20-cm and 36-cm nails. Coronal translation was 6.3 mm and 4.3 mm, respectively. With a single proximal locking bolt, average sagittal translation was 7.6 mm and 2.2 mm, respectively, for the 20-cm and 36-cm nails. Coronal translation was 13.6 mm and 4.4 mm, respectively. A statistically significant difference in fracture site translation was found in each pairing by Student t test (P < 0.005), except coronal translation with 2 proximal locking bolts (P = 0.056). Free-body analysis predicts higher local stresses at the proximal interlocks of the shorter nail. CONCLUSIONS: Longer nails provide improved initial fracture stability when compared with short retrograde nails for supracondylar femur fractures due to a more stable mechanical interaction between the femoral diaphysis and the nail. A second proximal locking bolt in the long nail provides no additional stability.

Bone Nails↗

PubMed2004

Mismatch of current intramedullary nails with the anterior bow of the femur.

OBJECTIVES: The anterior curvature of the femur affects intramedullary nail insertion, revision prosthesis design, and the biomechanics of the proximal femur. Two previous studies, using small numbers of femurs, determined femoral curvature and showed that it was significantly greater than that of the several intramedullary nails they evaluated. In this study, the curvature of 948 femurs (474 matched pairs) was determined and compared with current intramedullary nails. The correlation of femoral curvature to age, gender, femoral size, and race was also evaluated. SETTING: Museum skeletal collections and a hospital biomechanics laboratory. METHODS: The curvature of 892 femurs (446) from the skeletal collections of 2 museums was measured by processing the digital images of the femurs with a computer curve-fitting program. Fifty-six additional, embalmed femurs (28 pairs) from our collection were also digitally imaged and then radiographed and their medullary curvatures similarly determined for comparison. Curvatures of 8 current antegrade intramedullary nails and 3 long-stemmed femoral hip prostheses were obtained from manufacturers and confirmed by measurements from their templates after digitization. RESULTS: We found the average femoral anterior radius of curvature was 120 cm (+/- 36 cm). There was no effect of age on femoral curvature nor was there a correlation between femoral width or femoral length to curvature. Black donor femurs had less curvature than white donor femurs (P < 0.001). There was close correlation (r = 0.967) between the femoral curvatures determined from the digital images and the radiographs. Radii of curvature of the intramedullary nails ranged from 186 to 300 cm (eg, straighter than the femurs). CONCLUSIONS: There was a large mismatch between the curvature of some current antegrade intramedullary nails and the average femur. Although this is only 1 factor affecting nail insertion, the mismatch warrants a reappraisal of these intramedullary nail designs. CLINICAL RELEVANCE: Because ease of intramedullary nail insertion and possibility of cortical comminution are determined by a number of factors including insertion point and fracture location, it appears that a decrease in radii of curvature (less straight) of current nail designs is warranted, particularly for those larger diameter nails designed for hip fracture stabilization that have greater rigidity due to design or material.

Anthropometry↗

PubMed1988

Patterns of expression of trichocytic and epithelial cytokeratins in mammalian tissues. III. Hair and nail formation during human fetal development.

Cells forming hair and nail material are characterized by the synthesis of members of a particular group of alpha-keratin polypeptides (trichocytic cytokeratins. "T cytokeratins") different from epithelial cytokeratins ("E cytokeratins"). As the precursor cells to trichocytes are derived from fetal epidermal keratinocytes expressing only E cytokeratins, we have studied the patterns of expression of both T and E cytokeratins in developing human hair-and nail-forming tissues of different fetal stages, by immunocytochemistry using antibodies specific for certain T or E cytokeratins and by two-dimensional gel electrophoresis and immunoblotting. In developing hair follicles up to the early bulbous-peg stage (weeks 12-15 of gestational age), only certain E but no T cytokeratins were identified. T cytokeratins were first detected in the late bulbous-peg stage (in week-14 scalp skin) in certain cells of the central part of the hair cone. In hair-producing follicles (weeks 18-25), the lower hair matrix cells were positive for certain E cytokeratins, whereas T cytokeratins appeared in the uppermost portion of the matrix and, most prominently, in the maturing trichocytes. From the late bulbous-peg stage on. E cytokeratin antibody Ks13.1 selectively decorated the inner root sheath. In finger nail "anlagen", T cytokeratins were detected first in week 12 and 13 fetuses, specifically in cells of the lunula region. In more-advanced stages of nail formation, expression of T cytokeratins extended not only to the upper layers of the ventral nail matrix but was also found, albeit more sparsely, in cells of the whole nail-bed epithelium. Throughout these developmental stages, coexpression of T and E cytokeratins was noted in certain cells, including E cytokeratin 19. While in earlier stages E cytokeratins 10/11, characteristic of epidermal-type cornification, were noted in different regions, including the superficial stratum of the nail bed epithelium, they were later restricted to the epithelium of the proximal nail fold. The results show that terminal trichocytic differentiation starts, both in ontogeny and during the steady growth of hairs and nails, in cells expressing E cytokeratins and that coexpression of E and T polypeptides occurs in both kinds of appendages. While in the hair follicle, the change to the exclusive synthesis of T cytokeratins appears to take place relatively abruptly and simply, the development of nail structures from the ventral nail matrix seems to be more gradual and is characterized by more-complex patterns of coexpression of both kinds of cytokeratins.

Antibodies, Monoclonal↗

PubMed1990

The harlequin nail. A marker for smoking cessation.

Changes in the human nail frequently serve as an indicator of local and systemic disease. Alterations in the morphology, structure and growth characteristics of the nail accompany chronic cigarette smoking; yellow pigmentation of the nail plate--referred to as the "nicotine sign"--is common. The clubbed yellow nail may indicate the presence of lung cancer. In contrast to the ominous nature of the clubbed yellow nail, we describe a sign that is more propitious: the sudden cessation of smoking due to an intercurrent disease, often a cerebrovascular accident (CVA), leads to the development of a distinct line of demarcation between the distal pigmented nail and the newly emerging proximal nonpigmented nail. We propose the term "harlequin nail" for this curious physical sign. By measurement of the distance between the proximal nail base fold and the line of demarcation, we can deduce the date smoking ceased (and, by inference, the approximate date of a CVA in a patient unable to volunteer this information). This sign also serves as a reminder that the "nicotine nail" remains discolored only because of dynamic restaining of the nail with tobacco by-products.

Aged↗

PubMed2003

Yellow nail pigmentation following Depakote therapy.

Two months after being started on Depakote (divalproex sodium: Abbott Laboratories Inc., Abbott Park, Illinois), a 57-year-old female noticed the development of a transverse yellow band on all 20 proximal nails that eventually led to complete nail plate discoloration. Six to eight weeks after discontinuation of Depakote, normalization of her proximal nail plates was noted. Other anticonvulsants such as phenytoin and lithium have been documented to lead to nail pigmentation. Although several dermatologic reactions to Depakote have been described, we are not aware of any reported cases of nail discoloration secondary to Depakote. While our patient did have a history of renal disease with azotemia, we find it highly unlikely to be a contributing factor secondary to the fact that our patient's abnormality did not present similar to the nail abnormalities of renal disease. In conclusion, we found the temporal relationship between Depakote initiation/discontinuation and the nail discoloration to be highly indicative of Depakote as the source. Other anticonvulsants such as phenytoin and lithium have been documented to lead to nail pigmentation. Although several dermatologic reactions to Depakote have been described, we are not aware of any reported cases of nail discoloration secondary to Depakote. While our patient did have a history of renal disease with azotemia, we find it highly unlikely to be a contributing factor secondary to the fact that our patient's abnormality did not present similar to the nail abnormalities of renal disease. In conclusion, we found the temporal relationship between Depakote initiation/discontinuation and the nail discoloration to be highly indicative of Depakote as the source.

Antimanic Agents↗

PubMed2006

Using flexible nails to improve stabilization of proximal femur fractures in adolescents.

Intramedullary fixation as a treatment for adolescent femur fractures has increased in popularity. We investigated the varus stability of 3 fixation techniques--the standard 2-nail configuration (2 retrograde nails), a 3-nail configuration (standard 2-nail configuration plus 1 antegrade nail), and a retrograde/antegrade 2-nail configuration--in synthetic femurs with 2 simulated fracture patterns (transverse, butterfly). A varus moment was applied to the specimens until 20 degrees of varus angulation was obtained. The varus angular stiffness of the construct defined varus stability. The 3-nail configuration had the most varus angular stiffness with both fracture patterns. The varus stability of the 3-nail configuration was statistically higher than that of the standard 2-nail configuration with the transverse fracture pattern only. Adding 1 antegrade nail to 2 retrograde nails significantly increased resistance to varus deformity of reduced proximal-third transverse femur fractures in the synthetic femur model.

Adolescent↗

PubMedDate not supplied

A biomechanical comparison of unlocked or locked reamed intramedullary nails in the treatment of mid-third simple transverse femoral shaft fractures.

BACKGROUND: Despite that a mid-third simple transverse femoral shaft fracture has been traditionally treated with an unlocked reamed intramedullary nail, recently a static locked reamed intramedullary nail has been favored by some orthopedists to avoid missing extended fracture lines. A prospective comparison of both nails was conducted to investigate the superiority between the nails from biomechanical viewpoints. METHODS: Seven pairs of fresh healthy cadaver femora underwent mid-third transverse osteotomy. Consequently, all seven left femora were stabilized using Kuntscher nails and all seven right femora, static Russell-Taylor locked nails. Finally, all 14 femora were tested using a Material Testing System (MTS) machine to investigate the sustained mechanical loads, the maximal failure load, and the relative fragment displacement. RESULTS: The locked nails produced the larger mechanical loads (p = 0.02). The unlocked nails had the larger fragment displacement (p = 0.02) and the higher maximal failure load (6090 verse 5590 newtons, p = 0.02). All tests ended due to basal neck oblique fractures. CONCLUSIONS: Biomechanically, an unlocked nail, being a load-sharing device, is superior to a static locked nail, being a load-bearing device, in the treatment of a mid-third simple transverse femoral shaft fracture. Clinically, careful investigation of the fracture types and adequate selection of the nail type should be performed in treating these types of fractures.

Adult↗

PubMed1987

Flexible intramedullary nailing of femoral shaft fractures.

Simple flexible intramedullary nailing is a suitable method of fixation of femoral shaft fractures with stable configurations. Complications are rare when nailing is properly executed, and patients are able to ambulate and bear weight within days of surgery. Problems arise when simple nailing is used to fix femoral shaft fractures with unstable configurations. Sliding of nails out of portals, loss of fixation, malrotation, and knee pain often result. Therefore, adjunctive measures must be used in the fixation of unstable fractures. The technique of nailing is demanding. The surgeon must be familiar with the principles of intramedullary nailing and should observe several procedures before attempting to do one alone. Furthermore, it is advisable to start with simple nailing of fractures with stable configurations to gain experience and confidence before undertaking a more complex procedure in a fracture with an unstable configuration. Finally, it must be emphasized that the principles of intramedullary nailing are essentially the same for all intramedullary devices. It must be also emphasized that there is little room for fast, temporary nailings and that there is no substitute for solid, precise fixation. There is no difference between quick insertion of a Küntscher-type rigid nail without reaming and speedy flexible nailing--both are fast and both will result in failure of fixation. The surgeon should resist the temptation to do fast procedures.

Adolescent↗

PubMed1996

[Borderline indications for locked intramedullary nailing of femur and tibia].

The borderline indications of locked intramedullary nailing of the femur and the tibia, based on Küntscher nailing, are defined by the location of the fracture, the associated soft tissue injury, the appearance of infection and the patient's pulmonary status. From 1975 to 1995 at the Department of Traumatology, Vienna University School of Medicine, 551 patients with 559 femoral fractures and 536 patients with 548 tibial fractures were stabilized using locked intramedullary nailing. A total of 135 (24%) proximal femoral fractures were stabilized using intramedullary locking nails in 54 cases, and using long gamma nails in 81 cases. Ninety-one distal femoral fractures (16%) were stabilized in 82 cases with intramedullary locking nails and in 9 cases using retrograde nailing. In open fractures predominantly a reamed technique was used. Fifty-two of these fractures were femoral fractures and 101 were tibial fractures. Seventy-two femoral fractures (13%) were associated with compromised pulmonary function and polytrauma. Procedural changes from external fixation to the intramedullary locking nail technique were performed in 21 cases of femoral fractures and in 21 cases of tibial fractures. Six tibial fractures diagnosed as having compartment syndrome were treated using unreamed nailing and fasciotomy. The overall infection rate of femoral fractures was 1.7% and 1.9% for all tibial fractures; the nonunion rate of both femoral and tibial fractures was 0.5%. Because of the success rate observed in the treatment of borderline indications for locked intramedullary nailing of femoral and tibial fractures and the improvement in equipment, training and techniques, we have expanded the indications for treatment of these fractures by intramedullary nailing.

Adult↗

PubMedDate not supplied

[Vascular networks of the periphery of the finger nail].

The vascular networks of the periphery of the nail of the finger are studied on fingers of adults, fetus and newborns, by injecting the vascular system with gelatinous Indian ink. The nail is an avascular horny structure, partially covered with the nail fold. It is lying on a nail bed which prolonges forwards with the hyponychium. Each part of the nail apparatus (nail fold, matricial and unmatricial parts of the nail bed, hyponychium) presents a characteristic network which is tributary of dorsal collaterals arising from the digital palmar vessels and from their arcades. These networks are papillar, pseudopapillar, reticular and subdermical. The morphology and density of these networks vary according to their localisation and are superimposed with the histological variations of the different parts of the nail apparatus. Thus the matricial part of the nail bed shows a poor vascularization. It corresponds to the germinative part of the nail and is responsible of the color of the lunula. The unmatricial part of the nail bed and the hyponychium have dense vascular networks with glomi.

Adult↗

PubMed1991

The nail apparatus in collagen disorders.

Patients with collagen disorders may have a broad spectrum of nail changes. This article reviews the modifications of the nail apparatus that can be observed in the following diseases: systemic sclerosis, systemic lupus erythematosus, dermatomyositis, mixed connective tissue disease, rheumatoid arthritis, periarteritis nodosa, and Wegener granulomatosis. In all collagen diseases, the proximal nail fold is the most important site of alterations, and a careful inspection of this nail constituent is an essential part of the patient's routine clinical evaluation. Erythema and telangiectasia associated with visualization of the capillary loops are frequent findings; nail fold capillary hemorrhages and focal necrosis are also observed. The nail fold capillary microscopy abnormalities and the special nail changes that can be observed and characterize each collagen disorder are described. A careful clinical examination of the nail and a capillary microscopy study of the prossimal nail fold may, therefore, be decisive for the diagnosis of the collagen disorders. In fact, the nail unit alterations may give a clue that should not be overlooked.

Capillaries↗

PubMed1995

Intramedullary nailing of aseptic tibial nonunions without the use of the fracture table.

Twenty-seven patients with 28 aseptic nonunions were treated with reamed intramedullary (IM) nailing of the tibia and were followed for at least 1 year postoperatively. The management protocol called for a radiolucent operating room table with the limb draped free and manual manipulation of the nonunion with a preference for closed nailing. Nail interlocking was used when residual axial or rotational instability was observed after nail insertion. Iliac crest bone grafting was performed on all patients requiring open nailing. Closed nailing, using the described technique, was accomplished in 20 cases; open nailing was necessary in eight. Although operative time and total blood loss were significantly increased with open nailing, time to union was similar in the two groups. Twenty-seven nonunions healed. The lone persistent nonunion responded to bone grafting, leaving the nail in situ. One infection occurred, which responded to debridement, drainage, and long-term antibiotic therapy without requiring nail removal. Acceptable bony alignment was attained in all patients. Functional results were excellent. This method is recommended for all tibial nonunions amenable to IM nail stabilization. A history of prior acute infection and/or excessive shortening due to bone loss constitute the relative contraindications.

Adolescent↗

PubMed1999

Current topics in nail surgery

BACKGROUND: Nail surgery can be performed in an office-based dermatology practice with a limited amount of specialized equipment and training. Several excellent reviews have been published in recent years that detail the techniques of nail surgery for both the novice and the experienced practitioner. OBJECTIVE: In this article recent developments in nail surgery are discussed. Topics that are treated include the general principles of nail surgery, including epidemiologic issues, studies of nail anatomy, instrumentation, and anesthesia. The reconstruction of injuries and congenital defects involving the nail is explained, and the role of the hand surgeon clarified. Appropriate removal of tumours and cysts is considered, with special attention to the management of malignant lesions. The controversy regarding more or less conservative management of melanonychia striata is addressed, and the need for early diagnosis of subungual melanoma is emphasized. Other topics are surgical management of ingrown nails and onychomycosis. Newer areas of nail surgery, such as laser surgery of the nail, psychodermatology of the nail, and the role of primary care physicians in simple nail surgery are also examined.

Journal Article↗

PubMed1989

[Current indications for intramedullary bundle nailing].

Hackethal developed the nailing procedure named after him in 1959. The original method consisted in two steps: a non-sterile step in which mechanical reduction was performed with a traction device and a sterile step, i.e. nailing. The rationale of Hackethal nailing is an elastic jamming, which can only be achieved by obeying four rules: jamming of the nails in the cortical window, jamming then in the waist of the medullary cavity, spreading the bunch of nails in the metaphysis and filling up the conus of the medullary cavity with short nails. Hackethal believed it was possible to achieve an elastic jamming in all transverse and short oblique fractures of the shaft. He used his technique in fractures and non-unions of femur, tibia, humerus, radius and ulna. Extensive indications led to overuse of the method and resulted in a major rate of complications. Meanwhile, plating of shaft fractures has proved to involve an unexpectedly high rate of complications, and locking nails and new types of fixators have enlarged the surgeon's armamentarium for stabilization of fractures. Therefore, it seemed important to determine the present indications for Hackethal nailing. We confined Hackethal nailing to fractures of the middle third of the shaft in the upper extremity. All second- and third-degree open fractures were treated with fixators. In a 13-year period we performed Hackethal nailing of the humerus in 53 cases, of the radius in 20, of the ulna in 17, and in both of the forearm simultaneously in 12 cases. Plating and Hackethal nailing were combined for the treatment of forearm fractures in 10 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone Plates↗

PubMed1997

[A break or bend in the unreamed tibial intramedullary nail. Experimental study].

The intramedullary tibial nail with a proximal angle according to Herzog was developed in order to facilitate implantation. However, the modified technique of unreamed nailing also required a shift of the point of insertion; as a consequence the proximal angle required a considerable increase in the force necessary to introduce the nail. In a study using-four cadaver bones and five commercially available unreamed femoral and tibial nails, the authors demonstrate this considerable increase in insertion force and the development of pressure in the medullary cavity. The measurements made with our experimental setup clearly show that the proximal angle of the unreamed tibial nails available for our series does not have a favourable influence on insertion behaviour. As it appears, it results in an increase in the force required for insertion of the nail, thus also causing a greater strain on the bone and an increase in pressure in the medullary cavity. In contrast, the continuous bend of the nail results in a much smoother course of pressure development in the medullary cavity, which does not reach the same high values as with the unreamed tibial nails, despite the fact that less time is required for insertion of the nail. In our opinion, modification of the axial shape of the nail would result both in better implantability and easier removal. We therefore advocate such a modification of the axial shape of intramedullary tibia nails.

Biomechanical Phenomena↗

PubMed1998

[Antegrade or retrograde intramedullary nailing in diaphyseal or sub-capital humeral fractures in the adult].

The aim of this retrospective study was the evaluation of three current medullary nailing techniques and their approach related problems in diaphyseal and proximal humeral fractures. 28 patients (15 female, mean age 65 y; 13 male, mean age 53 y) with either diaphyseal (n = 22) or proximal humeral (n = 6) fractures treated with different nailing systems were reviewed (mean follow up 18.3 months). Two main groups were formed according to the surgical approach: an anterograde nailing group (AN), stabilized with Seidel (Howmedica) nails (n = 12) versus a retrograde nailing group (RN) with either Prévot (Landos) nails (n = 7) or Hackethal (Ulrich) nails (n = 9). The two groups were comparable regarding to age, follow up and fracture type. The subjective scores (global function, all day activity, pain, ROM) of the two groups (AN and RN) showed no statistically significant differences. Subacromial impingement led to reoperation in 50% (6/12) of the AN patients (Seidel nail). In 3/16 patients a reoperation was necessary due to secondary proximal or distal nail migration (Hackethal or Prévot nails). Delayed union was found either in one. Seidel or one Prévot nailed humerus. No postoperative infections or neurological problems (3 preoperative radial palsies recovered) due to the operative pro cedure were seen. The AN related subacromial impingement seems to be more disabling than RN related reduction of elbow function (extension deficit).

Adult↗