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PubMed1997

Biomechanical analysis of nonreamed tibial intramedullary nailing after simulated transverse fracture and fibulectomy.

A tibial shaft fracture model was created to study the effects of an intramedullary nail and partial fibulectomy on fracture loading. Cadaveric lower extremities were instrumented with strain gages and subjected to biomechanical testing. A nonreamed nail was inserted into each tibia using only the proximal locking screws. Each specimen was tested under six conditions: intact tibia; intact tibia with nail; fractured tibia with nail removed and fibula intact; fractured tibia with nail and fibula intact; fractured tibia with nail and partial fibulectomy; and fractured tibia with partial fibulectomy and nail removed. In the intact tibia the anterior cortices were in relative tension compared with the posterior cortex. After transverse fracture this relative tension was increased. Inserting the nail after fracture significantly increased anteromedial and anterolateral compressive strains and decreased posterior strains. Performing a partial fibulectomy in the fractured tibia with a nail had no significant effect on the strain patterns. These results confirm the relative anterior tension present in the intact tibia and demonstrate an increase in this anterior tension following transverse fracture. Performing a partial fibulectomy or inserting an intramedullary nail increased anterior compressive loading. This loading alteration may be responsible for the clinical success seen using these treatment methods.

Analysis of Variance↗
PubMed1999

Anterior knee pain after intramedullary tibial nailing.

BACKGROUND: Currently, intramedullary nailing is a well-accepted method for treating tibial shaft fractures, but some patients complain of anterior knee pain after surgery. Multiple factors may influence this troublesome complication. METHODS: This was a retrospective analysis of the medical records of 200 patients who were treated with intramedullary nailing after tibial shaft fractures. Sixty-four patients complained of knee pain after surgery. We evaluated the knee pain in relation to the surgical approach, radiographic readings, and the type of nail used. RESULTS: Among the 64 patients, 45 (70%) received central approaches and 19 (30%) received paramedial approaches (p = 0.0002); 46 patients (72%) showed nail protrusions on radiographs and only 18 patients (28%) were without nail impingement (p = 0.0001). Forty-three patients (67%) received Kuntscher nail fixation and just 21 patients (33%) had interlocking nail fixation (p = 0.0015). CONCLUSION: The use of the central patellar tendon splitted approach, nail protrusion observed on radiographs, and the insertion of a non-locking intramedullary nail were all significant risk factors for anterior knee pain after surgery. All these risk factors should be avoided in tibial nailing to decrease the problem of postoperative knee pain.

Fracture Fixation, Intramedullary↗
PubMed2003

Nonunion following intramedullary nailing of the femur with and without reaming. Results of a multicenter randomized clinical trial.

BACKGROUND: Intramedullary nailing of the femur without reaming of the medullary canal has been advocated as a method to reduce marrow embolization to the lungs and the rate of infection after open fractures. The use of nailing without reaming, however, has been associated with lower rates of fracture-healing. The purpose of this prospective study was to compare the rate of union of femoral shaft fractures following intramedullary nailing with and without reaming. METHODS: Two hundred and twenty-four patients were enrolled in a multicenter, prospective, randomized clinical trial to compare nailing without reaming and nailing with reaming. One hundred and six patients with 107 femoral shaft fractures were treated with a smaller diameter nail without reaming of the canal, and 118 patients with 121 fractures had reaming of the canal and insertion of a relatively larger diameter nail. Patients were followed at six-week intervals until union occurred or a nonunion was diagnosed. RESULTS: The two groups were comparable with regard to the measured patient and injury characteristics. Eight (7.5%) of the 107 fractures in the group without reaming had a nonunion compared with two (1.7%) of 121 fractures in the group with reaming (p = 0.049). The relative risk of nonunion was 4.5 times greater (95% confidence interval = 1 to 20) without reaming and with use of a relatively small-diameter nail. CONCLUSION: Intramedullary nailing of femoral shaft fractures without reaming results in a significantly higher rate of nonunion compared with intramedullary nailing with reaming.

Adult↗
PubMed1994

[Intramedullary pressure in intramedullary nailing of the femur and tibia].

Intramedullary nailing of shaft fractures of the femur and tibia is a recognized operative procedure and its use has even been enlarged by the introduction of the so-called interlocking technique. In recent years case reports have been published describing peroperative pulmonary embolism during reamed femoral nailing, suggesting either an unfavorable effect of the reaming or the pressure increase in the medullary cavity while reaming and nailing. In an in vitro study on explanted human femora and tibiae we investigated the intramedullary pressure increase in reamed and unreamed nailing procedures of both bones. A lower pressure increase was noted in unreamed nailing compared to reamed nailing in the femur (289/496 mm Hg) and in the tibia (128/>833 mm Hg). The unreamed tibial nailing displayed significantly less pressure increase than the unreamed femoral nailing (p = 0.01). Opening of the medullary cavity with the so-called cheese cutter (cannulated cutter over a centering pin) showed significantly greater pressure increase in the femur than in the tibia (p = 0.01). Pressure increase seems to be dependent of the mode of insertion of the unreamed nail (ram-blows versus manual insertion), although the difference in the tibial unreamed nailing is statistically not significant.

Biomechanical Phenomena↗
PubMed1995

[Penetrating injury of the head, neck and chest by a nail-gun: a case report].

A very rare case of directly penetrating injury of the head, neck and chest caused by a nail-gun was reported. A 56-year-old male was admitted to our critical care center due to chest injury. On admission, he showed numbness of the hand & leg, left hemiparesis and hypalgesia. Physical examination disclosed three nails on the left anterior chest, but other wounds or nails were not found. Chest films showed three nails penetrating the lung without reaching the heart, but other nails were found by skull and neck films. One nail had penetrated the cervical canal at the C1 level through the posterolateral cervical region. Two other nails were demonstrated at the right temporal and the left frontal region, Computed tomography revealed no massive cerebral hemorrhage and cerebral angiography showed no extravasation and no passage through main vessels. Emergency surgery was performed uneventfully and the nails in the chest, neck and head were totally removed. He was discharged one month after surgery. Some injuries caused by a nail-gun have been reported in the world literature but in Japan this multiple injury case was the first reported. Since nail-gun injuries can cause multiple damage, systemic X-ray examination was very important.

Cervical Vertebrae↗
PubMed2003

[Nail changes during childhood].

Nail changes occur frequently in adults, but are relatively rare in children. There are, however, certain nail changes that emerge particularly during childhood. Ingrown nails, onychoschizia, congenital slanted alignment of the large toenail, and psoriasiform nail dystrophies can be frequently observed in toddlers and in schoolchildren the syndrome of an ingrown nail, nail artifacts, periungual warts or fibromas, trachyonychia, and nail mycoses. Connatal nail changes can appear as isolated events or together with other symptoms whereas acquired nail changes are caused by infections, traumatic injuries, or tumors, in conjunction with skin diseases or general illnesses, or even develop spontaneously.

Child↗
PubMed1986

The nails in adult type 1 pityriasis rubra pilaris. A comparison with Sézary syndrome and psoriasis.

The fingernails of twenty-four patients with classical adult (type 1) pityriasis rubra pilaris were examined for changes in nail morphology and a comparison was made with the fingernail morphology of twenty-seven consecutive psoriatic patients with nail changes. Distal yellow-brown discoloration, subungual hyperkeratosis, nail plate thickening, and splinter hemorrhages indicate a diagnosis of type 1 pityriasis rubra pilaris rather than psoriasis, while onycholysis (particularly marginal), salmon patches, small pits, and larger indentations of the nail plate indicate a diagnosis of psoriasis. Histology demonstrated that a nail biopsy would be a useful diagnostic procedure if nails were involved in isolation but provided no additional diagnostic features to those found from biopsy specimens of involved skin in the two conditions. The similarity in nail morphology between the type 1 pityriasis rubra pilaris patients and five patients with chronic erythroderma resulting from Sézary syndrome indicated that these changes may represent a nonspecific reaction pattern that may result from prolonged erythema of the proximal nail bed and matrix. The rough nails (trachyonychia) described in advanced Sézary syndrome were not observed in any of our patients.

Humans↗
PubMed1996

Nail matrix nevi: a clinical and histopathologic study of twenty-two patients.

BACKGROUND: Because most dermatologists do not regularly perform biopsies of longitudinal melanonychia, even when the pigmentation presents as a single band, the true prevalence of nail matrix nevi is unknown. OBJECTIVE: Our purpose was to determine the prevalence of nail matrix nevi in white patients with longitudinal melanonychia involving a single digit and to determine whether longitudinal melanonychia caused by a nail matrix nevus can be clinically distinguished from longitudinal melanonychia from other causes. METHODS: From January 1989 to December 1994 we performed a nail biopsy on 100 of 128 consecutive white patients who had a single band of "idiopathic" longitudinal melanonychia. RESULTS: A nail matrix nevus was detected in 22 patients. A junctional nevus was found in 19 specimens and a compound nevus in three specimens. CONCLUSION: Nail matrix nevi in Caucasian patients are uncommon but not exceptional. The number of nevi presenting with longitudinal melanonychia exceeded that of melanoma. The diagnosis of nail matrix nevi is impossible clinically and always requires histopathologic study. The pathologic features of nail matrix nevi are similar to those of skin nevi except for their architectural pattern, which reflects the peculiar anatomy of the nail unit.

Adolescent↗
PubMed1983

Nail bed repair and reconstruction by reverse dermal grafts.

Repair of traumatized nail beds and reconstructive procedures for nail deformations often lead to less than satisfactory results. This series of 19 patients had reverse dermal grafts applied either because of acute traumatic nail bed avulsion (nine patients) or for secondary reconstruction of a scarred nail bed with nail deformity (10 patients). Excellent results with nearly normal nail cosmesis were obtained in seven of nine primary nail bed repairs, whereas seven of 10 secondary reconstruction procedures ultimately had poor results. We conclude that the technique of reconstituting a nail bed with a reverse dermal graft for acute nail bed avulsion can lead to predictably satisfactory results.

Adult↗
PubMed2001

Nail dystrophy due to lichen sclerosus?

Lichen sclerosus (LS) affects anogenital skin alone in 80% of cases. When extragenital disease occurs, it usually affects the trunk, neck, axillae and wrist flexures. Nail involvement with LS is rare. In contrast, lichen planus (LP) commonly affects extragenital skin. Mucosal lesions occur in 50% of cases, affecting the mouth and genitalia. Nail disease in LP is common, and, if severe, can lead to destruction of the nail bed. LS and LP can coexist. We report two cases of LS with nail involvement. In the Case 1 disease was confined to the nail, and nail biopsy confirmed LS. In the Case 2, the nail changes formed part of the widespread genital and extragenital LS, confirmed histologically. We review existing literature on nail disease in LS and discuss the possible aetiology of the nail changes.

Administration, Topical↗
PubMed1994

Idiopathic trachyonychia (twenty-nail dystrophy): a pathological study of 23 patients.

We report the clinical features and pathological findings in 23 patients with idiopathic trachyonychia (twenty-nail dystrophy). Clinically, the nail changes in the majority of patients consisted of the typical 'sandpapered' appearance, with a rough, lustreless nail plate. In some, however, the nail plate abnormality was less severe, with numerous small, superficial pits, which imparted a shiny appearance to the surface of the nail. Histology of nail biopsy specimens showed spongiotic changes in 19 patients, psoriasiform features in three, and features of lichen planus in one patient. The mean follow-up of these patients was 2 years, during which time none developed alopecia areata or mucocutaneous lesions. Idiopathic trachyonychia is therefore a consequence of several inflammatory disorders, which produce a disturbance of nail matrix kinetics. The course of the inflammation and the extent of the inflammatory process within the nail matrix produce two different patterns of nail plate surface abnormalities.

Adolescent↗
PubMed2000

[Fungal and bacterial nail infections].

Fungal and bacterial infections are very common causes of nail deformity. The majority of fungal nail infections are caused by dermatophytes. Dermatophytosis result from a human contamination. A dermatophyte is always a pathogenic agent. Very effective drugs are available to treat dermatophyte nail infections. Yeasts of the genus Candida, notably C. albicans are the second most common cause of nail infection. The infections of nails due to Candida and bacteria are related with Candida sp and bacteria which are common commensals of the gastrointestinal tract, vagina or skin. Except C. albicans which is always a pathogen of skin, the other species of Candida and the bacteria could be a commensal of the skin, a colonizer of a dermatological disease or a true pathogen of nail. It is important to consider these different situations. More rarely, environmental moulds, most often known as saprophytic agents, can affect nails. They do not respond to conventional antifungal drugs. So, their diagnosis do not suffer any error. In order to evaluate properly the patient with possible fungal or bacterial infection of nails and also to choice an accurate therapy, the laboratory confirmation is essential. Clinical diagnosis is not sufficient to distinguish an infection of nails from a dermatological disease (psoriasis, traumatism) and to identify the responsible agent.

Anti-Bacterial Agents↗
PubMed2006

Nail and distal interphalangeal joint in psoriatic arthritis.

OBJECTIVE: To study distal interphalangeal (DIP) joints in patients with psoriatic arthritis (PsA) with or without onychopathy, using magnetic resonance imaging (MRI). METHODS: Twenty-three patients with PsA (9/14 F/M, median age 47 yrs), 12 with onychopathy (2/10 F/M, median age 44 yrs) and 11 without (7/4 F/M, median age 52 yrs), and 10 control subjects (5/5 F/M, median age 43.2 yrs) were enrolled. MRI of nail and distal phalanx (DP) including examination of DIP joints was carried out. MRI was performed with a surface coil in a 1.5 T device. For each selected finger, both longitudinal and axial scans were performed. The involvement of nail, DP, and DIP joint was scored. RESULTS: Nail thickening with or without surface irregularity occurred in 95.7% of cases (100% with onychopathy and 90.9% without). MRI nail involvement was more frequent in patients with clinical evidence of onychopathy than in those without (p = 0.003). Similarly, 95.7% of patients showed MRI abnormalities of DP (100% with onychopathy and 90.9% without). MRI DP abnormalities were more marked in patients with clinical evidence of onychopathy than in those without (p = 0.009). Involvement of DIP joints was present in 34.8% of cases (58.3% with onychopathy and 9.1% without), and onychopathic patients showed marked MRI DIP joint involvement in 5 cases and mild in 2, while patients without onychopathy showed minimal changes in one case (p = 0.03). Considering the entire group of patients, MRI involvement of DIP joints was always associated with MRI DP changes, and in no case was it present alone. CONCLUSION: MRI nail involvement was present in almost all patients with PsA studied, even in those without clinically evident onychopathy. MRI involvement of DP always overlapped with nail involvement, since it was present in all psoriatic cases showing MRI nail involvement. In contrast, MRI DIP joint involvement was almost exclusively in a lower percentage of the patients with clinical nail involvement and was always associated with MRI DP changes. Our results suggest that DIP joint involvement is always secondary to nail and DP involvement.

Adult↗
PubMed2002

Dermoscopic examination of nail pigmentation.

BACKGROUND: Diagnosis of longitudinal melanonychia is usually difficult, and neither a single clinical criterion nor a combination of symptoms currently can be used to clearly distinguish malignant from benign bandlike pigmented nail lesions. Biopsy is painful and often leaves definitive dystrophic scars. OBJECTIVES: To describe and evaluate dermoscopic patterns associated with longitudinal nail pigmentation. PATIENTS AND METHODS: A total of 148 unselected consecutive cases of longitudinal melanonychia were included over a period of 4 years (20 melanoma, 37 nevi, 16 drug-induced nail pigmentation, 45 nail apparatus lentigo of various types, 8 ethnic-type nail pigmentation, and 22 subungual hemorrhages). All patients were recruited from the dermatology unit outpatient clinic of the Hôtel Dieu de Lyon. All cases were photographed in vivo under oil immersion (dermoscopy). Patterns were recorded prior to final pathologic diagnosis. An independent biostatistics unit performed statistical evaluation using 7 semiologic patterns. RESULTS: Melanoma cases were significantly associated with a brown coloration of the background and the presence of irregular longitudinal lines (P =.001). Blood spots were mostly observed in subungual hemorrhages (P =.001); however, their presence could not rule out melanoma. Micro-Hutchinson sign was observed only in melanoma, but its rare occurrence did not allow any statistical evaluation of its specificity. Nail apparatus nevi were significantly associated with a brown coloration of the background and the presence of regular lines (P =.001). Nail apparatus lentigo, ethnic-type pigmentation, and drug-induced pigmentation were significantly associated with homogeneous longitudinal thin gray lines and gray coloration of the background (P =.001). Microscopic longitudinal grooves were unspecific, occurred in several conditions, and were associated with any type of ungual discoloration. CONCLUSIONS: We believe that dermoscopic examination of the nail plate in cases of longitudinal melanonychia provides useful information that could help clinicians to more accurately decide if a nail apparatus biopsy should be performed; however, histopathologic diagnosis remains the gold standard in doubtful cases.

Adult↗
PubMed1998

Childhood injuries from artificial nail primer cosmetic products.

BACKGROUND: Methacrylic acid-containing primers used in artificial nail cosmetic products are typically not contained in child-resistant packaging, although they are sold to the general public. OBJECTIVE: To analyze the type and severity of childhood poisoning injuries involving methacrylic acid-containing artificial nail primers. DESIGN: Secondary analysis of 2 national, population-based injury data sets. SETTING: The 1991 through 1993 National Electronic Injury Surveillance System data on emergency department visits compiled by the Consumer Product Safety Commission and the 1993 through 1995 Toxic Exposure Surveillance System data on calls to poison control centers compiled by the American Association of Poison Control Centers. SUBJECTS: Children younger than 6 years with injuries associated with exposures to nail primers. RESULTS: In the National Electronic Injury Surveillance System, there were 769 exposures to nail preparations, 32 (4.2%) of which involved nail primers. Twenty-eight (87.5%) of 32 nail primer exposures involved children younger than 6 years. Of the severe nail primer injuries, 80% involved preschoolers; most of the injuries were dermal burns. In the Toxic Exposure Surveillance System data set, there were 759 methacrylic acid-containing nail product exposures, of which 567 (74.7%) occurred in children younger than 6 years. Of exposures in preschool children, 56 (9.9%) resulted in moderate severity injuries and 3 (0.5%) in "major" injuries; there were no deaths. CONCLUSIONS: Artificial nail primers containing methacrylic acid represent a corrosive hazard to young children and have been associated with severe injuries. New product labeling and packaging regulations and public education measures that recognize this hazard are recommended.

Adolescent↗
PubMed1997

Cellular features of differentiation in the nail.

Biochemical analysis indicated that the human nail plate contains two distinct types of keratin (skin-type and hair-type keratins), and several population of keratinocytes are thought to be associated with development of the nail. To elucidate the nature of the differentiation occurring in nail development, we examined the patterns of molecular markers relevant to the course of differentiation in the skin and hair in the nail matrix as well as in cultured nail cells. The nail matrix was characterized by the mutually exclusive localization of skin-type and hair-type markers, while in the apical matrix the localization of two groups of keratins partially overlapped. Double-label immunofluorescence showed the existence of unusual cells coexpressing both keratins, thereby indicating that the nail matrix consists of skin-type and hair-type and additionally intermediate-type differentiating cells. The cultured cells taken from the ventral matrix which develop under hair-type differentiation in vivo were found to express skin-type along with hair-type keratins, suggesting alteration of the pathway of differentiation in vitro. The cellular diversification as seen in in vitro cultured cells provides further insight into nail differentiation which is related to the multiple patterns of keratin expression that generate in the nail matrix.

Animals↗
PubMed1999

Intramedullary pressure and bone marrow fat extravasation in reamed and unreamed femoral nailing.

This study was designed to investigate whether intramedullary pressure and embolization of bone marrow fat are different in unreamed compared with conventional reamed femoral nailing in vivo. In a baboon model, the femoral shaft was stabilized with interlocking nailing after a midshaft osteotomy. Intramedullary pressure was measured in the distal femoral shaft fragment at the supracondylar region. Extravasation of bone marrow fat was determined by the modified Gurd test (range: 0-5) with blood samples from the vena cava inferior. Data were monitored in eight unreamed and eight reamed intramedullary femoral nailing procedures. Intramedullary pressure increased in the unreamed group to 76 +/- 25 mm Hg (10.1 +/- 3.3 kPa) during insertion of 7-mm nails and in the reamed group to 879 +/- 44 mm Hg (117.2 +/- 5.9 kPa) during reaming of the medullary cavity. Insertion of 9-mm nails after the medullary cavity had been reamed to 10 mm produced an intramedullary pressure of 254 +/- 94 mm Hg (33.9 +/- 12.5 kPa) (p < 0.05). Fat extravasation in the unreamed group was recorded with a score of 2.9 +/- 0.4 for the Gurd test during nailing with 7-mm nails, whereas in the reamed group significantly more fat extravasation was noticed during the reaming procedures, with a score of 4.6 +/- 0.1. Liberation of fat during insertion of 9-mm nails after reaming was recorded with a score of 3.5 +/- 0.4. In both groups, a positive correlation of fat extravasation with the rise in intramedullary pressure was found (reamed group: r(s) = 0.868; unreamed group: r(s) = 0.698), resulting in significantly less liberation of bone marrow fat in the unreamed stabilized group than in the reamed control group (p < 0.05). The data indicate that fat embolization during nailing procedures after femoral osteotomy increases with increasing intramedullary pressure and occurs in a lesser degree in unreamed than in reamed intramedullary femoral shaft stabilization.

Animals↗
PubMed2004

Complications following the treatment of trochanteric fractures with the gamma nail.

INTRODUCTION: The treatment of trochanteric fractures with the use of gamma nails has become an established method. Despite the good and reliable results, some typical failures and complications may occur. It was our purpose to analyse the most common complications and their treatment options. MATERIALS AND METHODS: A total of 498 patients were treated with a gamma nail from January 1992 until December 2001. There were 77% pertrochanteric, 10% subtrochanteric, 11% reversed pertrochanteric and 2% lateral femoral neck fractures. The patients' mean age was 78.6 years (ranging from 29 to 98 years). RESULTS: There were a total of 78 general complications (16%) and implant-related complications in 8% (n=42). The most common complication was trochanteric pain necessitating removal of the gamma nail (n=30). Four patients fell after removal of the nail and sustained a neck fracture on the same side. Cut-out of the screw occurred in 19 patients. Sixteen of them had to be converted to a total hip replacement. Another 5 patients were converted to a total hip replacement because of pseudoarthrosis. During conversion to total hip replacements, the trochanter major refixation and length adjustment were the most problematic steps (intra- or postoperative dislocations necessitating anti-dislocation rings in three cases). Furthermore, cement extrusion at the femur and acetabulum occurred in 13 cases. Infections occurred in 3 patients. Five patients with a short gamma nail needed a conversion to a long gamma nail due to pseudoarthrosis (n=2) or femur fracture at the distal interlocking bolt (n=3). In addition, 7 patients sustained a distal femur fracture through the distal bolt, necessitating a plate osteosynthesis. CONCLUSION: Most complications after gamma nail fixation can be prevented by following certain rules. The other inevitable problems can be dealt with either through a conversion to a total hip replacement, a re-osteosynthesis with a long gamma nail or an additional condylar plate. Conversion to total hip replacement may be a demanding operation with a higher than normal complication rate. Removal of the gamma nail should be performed cautiously as re-fractures can occur.

Adult↗