Introduction Clinical definition nail deformity that occurs caused by volar curving of the nail matrix Etiology Pathophysiology can be caused by tight closure of the fingertip during treatment fo distal tip amputation loss of bony support under the nail bed causing volar sloping of the nail bed Anatomy Perionychium consists of nail bed soft tissue beneath the nail includes germinal matrix (proximal) produces 90% of the nail scarring causes absence sterile matrix (distal) keeps nail adherent to nail bed injury causes deformity nail fold most proximal portion of the perionychium consists of ventral floor - germinal matrix portion of the nail bed dorsal roof eponychium skin proximal to the nail that covers the nail fold paronychium skin on each side of the nail hyponychium skin distal to the nail bed Presentation History patient will report fingertip injury in the form of trauma or infection in the past Symptoms common symptoms painless complaint is typically cosmetic in nature can become painful if it becomes in-grown Physical exam Careful inspection of the nail to identify any 'hooking' of the nail Imaging Radiographs typically needed to assess the bone stock/deformity of the distal phalanx tuft Treatment Nonoperative observation alone indications majority of patients not concerned about cosmesis prosthetic replacement Operative indications improving cosmesis painful, in-grown hook nail soft tissue manipulation - shorten bone, do not maintain nail bed length indications majority of distal tuft maintained when the distal nail bed has been closed/pulled over the distal tuft soft tissue + bony support - lengthen bone, maintain nail bed length indications lack of distal tuft/bony support Technique Soft tissue manipulation shorten bone, perform soft tissue procedure to correct 'hooking' of nail bed that advances soft tissue and reattach to dorsum of bone V-Y advancement cross-finger flap full-thickness skin graft Bony support procedure to maintain nail length options bone graft to distal tip free, vascularized bone graft from second toe Complications Lack of complete correction Recurrence of deformity Necrosis/flap failure, loss of distal tip