Ingrowing toenail and onychogryposis.

ingrowing toenail and onychogryposis cause much disability and discomfort. Pain, with inflammation or sepsis, is the presenting symptom of ingrowing toenail, and the disease is common in adolescents and young adults. Lloyd-Davies and Brill (1963) showed that correct trimming of the nails, with general care of the feet, socks and shoes did much to control and prevent the disease. If this treatment were unsuccessful avulsion and wedge excision had a place. In contrast, onychogryposis causes pain but is seldom associated with sepsis. It occurs spontaneously in the elderly and may follow trauma or repeated avulsion of the nail in persons of any age. In both conditions ablation of the nail and its growth bed is the logical procedure if simple treatment fails. The nail grows distally from the proximal nail bed, but the exact area from which a normal nail grows is uncertain. It is at least the plantar or ventral part of the bed proximal to the lunula. Two other areas appear to be significant: the lateral extension on to the lateral tufts of the phalanges and the dorsal aspect ofthe nail fold lying superficial to the nail. Samman (1959) showed that in abnormal circumstances the nail could grow from any part of the bed. Two operations are commonly used to stop growth ofthe nail: Syme’s terminal amputation, with removal of all the nail bed and half of the terminal phalanx (Stamm 1948); and the operation attributed to Zadik but originally described by Quenu in 1887, in which the distal half of the nail bed is left, and no bone is removed. Zadik (1950) and Fowler (1958) found this operation satisfactory. Fowler found only one recurrence in 100 cases followed for at least six months. He stressed the need for sharp dissection, a point which was not emphasised by Zadik. Lloyd-Davies (1963), using Zadik’s original technique, found the results disappointing. He found recurrence ofnail growth in three out offour ofhis patients. Rees (1964) also found Zadik’s operation unsatisfactory in two-thirds of his patients. He advocated Syme’s operation, which was satisfactory in nine cases out of ten.