First Violet, Op. 575, No. 8

First violet, Op. , no. 8 / Franz Behr. Loading content EDITION BEAUTIFUL The First Violet i E.B. 28 FRANZ BEHR Op. , No. 8.
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The nail matrix is intimately attached to the base of the terminal phalanx, and with its widening it becomes uncurved proximally which automatically causes overcurving distally.


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The heaped-up distal portion of the nail bed pulls the soft tissue up resulting in a traction osteophyte [ 4 ]. In neonates, the hallux nail may not yet have overgrown the distal rim completely which then may grow in either distally or distal laterally Figure 4. Infants sometimes present with a grossly hypertrophic medial nail wall that covers up to one half of the nail.

Keratotic debris is kept in the deep crypt between the nail and nail fold and when the debris is degraded by bacteria and yeasts an inflammation develops. A relatively common condition is congenital malalignment of the big toenail. From birth or shortly thereafter, the nail appears discoloured, thickened, triangular, and oyster-shell like. Probing reveals considerable onycholysis, the degree of which is probably the most important prognostic factor [ 5 ]. About one half of the cases is said to show spontaneous resolution; however, in those without improvement and treatment, the condition will result in early onychogryphosis.

Roentgenographic investigations have shown structures that were interpreted as a hypertrophic dorsal extension of the lateral ligament of the distal interphalangeal joint ending in the lateral matrix. This was thought to exert a constant pull on the lateral matrix horn with a resultant lateral deviation of the big toenail [ 6 ]. In the adolescent type, three stages of ingrown nail are differentiated [ 7 — 9 ]: Treatment depends widely on the degree of inflammation. The controversy begins with the acknowledgment of a particular aetiology and whether it should be conservative or surgical.

Naturally, the latter depends on the specialty of the treating person; podologists and pedicurists favour braces and similar devices, and some dermatologists use other non-invasive approaches whereas the majority tends to perform surgery. Physicians favouring noninvasive treatments consider the aetiopathogenesis of ingrowing nails to be due to a condition amenable to protecting the lateral nail fold from the offending distal nail edge. There are several different methods to achieve this goal, all of which require excellent patient compliance.

Taping is the least aggressive method. It uses tape to pull the lateral nail fold away from the offending lateral nail edge. Performed correctly and consistently, it can indeed achieve its goal in mild cases of ingrown nails [ 10 ]. The technique of taping is, however, crucial, and most patients require repeated education how to perform it. This is usually done in an oblique and proximal direction over the the pulp of the toe without impairing the joint movement and avoiding a circular constriction of the toe. A second, so-called anchor tape is applied over the beginning of the first one to fix it and exert even more pull on the distal nail fold [ 11 ].

The problem is with toenails that have caused granulation tissue as this is wet, and the tape does not remain stuck on this area. Wiping and drying it with acetone may be of help but is often not enough.

Several tape layers may absorb some humidity [ 12 ]. In summer time, sweating will also impair the sticking of the tape. Here, we recommend to use a very thin layer of mastisol, which makes the skin more sticky. Packing is another simple method. A wisp of cotton is inserted between the corner of the nail and the nail fold Figure 6.

This may first be a bit painful but the patients usually report immediate relief as soon as it has been done. The cotton may be soaked with an antiseptic or disinfectant. The procedure is repeated on a daily basis, each time trying to use a bit more cotton. When complete painlessness is achieved and the nail margin is no longer digging in, the cotton may be fixed with acrylic glue and stay on for a week or so.

The treatment period is long, but the results in stage 1 patients are good [ 13 ]. Consistent good care is necessary to avoid recurrences. Instead of cotton, dental floss was inserted under the nail corner in order to separate it from the nail groove [ 14 ]. Gutter treatment is the insertion of a small guard between the lateral nail margin and the nail fold [ 15 , 16 ]. A sterile plastic tube, most commonly from an intravenous drip infusion, is cut lengthwise to open it.

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Under local anaesthesia, the nail corner is elevated and the lateral nail margin freed so as to allow the gutter to be slid over it Figure 7. In contrast to the original publication [ 15 ], we do not excise the granulation tissue. The gutter is fixed with one or two stitches [ 15 ], tape or acrylic glue [ 16 ]. It is important not to cut the spicule of the nail as it gives additional support to the gutter Figure 7 [ 16 ]. This is left in place for a period of 6 to 8 weeks or even longer, during which the inflammatory changes will have subsided.

The gutter not only protects the lateral nail groove, but also exerts some pressure on it making the granulation tissue disappear even faster [ 16 ]. Nail braces are designed to open the curvature of the nail. Their main field of indication is nail overcurvature leading to pincer nail.

However, as flat nails rarely grow in the marked curvature apparently plays an aetiological role and is the main treatment goal of many podologists. The braces are made from steel wire or plastic bands. The wire is applied over the dorsal surface of the nail and hooked under its lateral edges. By tightening it, for example, by screwing, the curvature is decreased [ 17 ]. Plastic bands are glued on the nail and due to their memory will gently uncurve the nail [ 18 ].

Copper-aluminum-manganese-based shape memory alloys have a similar effect [ 19 , 20 ]. Many physicians give antibiotics when a patient presents with inflammation and granulation tissue. In my view, this is almost always a useless waste of resources as the nail that digs into the soft tissue is the cause of both the inflammation and granulation tissue. No nail has ever been shown to be sensitive even to the most powerful antibiotic.

Many surgeons who still use cold-steel surgery, particularly wedge excisions, routinely administer antibiotics. This may be justified as they cut through a heavily contaminated area deep into the periungual tissue. Foot baths and consistent foot hygiene are important factors during conservative treatment, to maintain its effect and as a preparation for surgery. Virtually all ingrown nails present with inflammation and consecutive bacterial colonization, the latter being considerably reduced by disinfective baths and removal of putrid scabs.

The number of surgical methods for the treatment of ingrown nails is huge; probably, there is hardly anyone knowing them all. New or presumedly new methods continue to be published. Many of them are just minor variations of old surgical techniques and very frequently do not bring the slightest progress.

Controversies in the Treatment of Ingrown Nails

Often, they show that the authors do not understand the aetiology and pathogenesis of this condition. There are two fundamentally different approaches. Elevation of the lateral nail margin and excision and cautery of the granulation tissue of the nail fold were already described by Paul Aegineta — and Abu al-Qasim, also known as Abulcasis — Fabrizius ab Aquapendente — excised and avulsed the ingrowing nail margin.

Michaelis gave a detailed description of various treatment methods as early as , [ 26 ] on which Emmert later based his surgical treatment [ 27 ]. Gosselin in had already counted 75 different varieties of local treatment and described a method, by which an elliptical wedge-shaped piece of nail matrix and skin including the whole nail groove along the edge was removed [ 28 , 29 ]. The Bernese surgeon Emmert in and proposed a wedge excision of the lateral nail wall, groove, adjacent nail, and matrix [ 30 ], which is in fact the method proposed by Baudens in [ 31 ].

It was also Emmert who had first described the three stages of ingrown toenails [ 27 ]. In the late s, there were more similarly radical surgical operations such as those of Hildebrandt [ 32 ]. He also noted that there are three ways to remove the cause, whether the nail grows down into the flesh or the flesh grows up against the nail; something may be interposed between the nail and the flesh—what is now known as packing—; the nail may be removed from the flesh; the flesh may be removed from the nail.

He proposed an incision to be carried out through the nail beginning at its free end and running parallel to the ingrowing edge, through the skin and matrix to allow skin flaps overlying the matrix to be reflected. The matrix attached to the nail strip was dissected [ 29 ]. This is in fact the first description of a selective matrix horn resection. The terminal Syme operation is even more radical and is in fact an amputation of the tip of the toe [ 36 , 37 ]. This short historical overview demonstrates what ingrown toenail sufferers had to face in the past. It is a shame that many of these obsolete methods are still performed by surgeons and other physicians treating ingrown nails although the most reasonable technique had already been described [ 29 ].

In the following, some methods will be briefly discussed; it is not possible to deal with all of those ever described. Nail avulsion causes significant postoperative morbidity. When the nail regrows, the plate is still as wide as it was before and will therefore grow in again. Further, during the period where there was no plate, the nail bed usually shrinks both longitudinally as well as transversely. Absence of the big toenail leads to dorsal dislocation of the most distal portion of the pulp of the toe with a resultant false distal nail wall because of lack of counterpressure of the nail plate during gait.

For a fraction of a second, the entire body weight is on the tip of the big toe plus the kinetic energy of the forward thrust resulting in two to two-and-a-half-fold the body weight. This is even more during sports activities. Once there is a distal nail wall, the nail plate cannot overgrow it. The matrix continues to produce nail substance which turns into a thickened, yellowish, and opaque nail with considerable onycholysis. Unfortunately, there are still practitioners and surgeons that avulse ingrown nails.

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