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Cases
Nail Changes After Cast Immobilization
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Background
This 30-year-old man fractured his right wrist and hand in a car accident. The hand and wrist were immobilized with a plaster cast for 45 days, during which time the patient complained of moderate paresthesia and pain.
Ten days after the cast was removed, the patient presented to the hospital with painful periungual inflammation on the fourth finger on his right hand. Physical examination revealed proximal onychomadesis (ie, nail detachment) and a bleeding vascular nodule protruding from the proximal nail fold. The adjacent third finger showed a Beau line.
The nail changes resolved spontaneously in 4 weeks. What is the diagnosis?
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Scroll down for Hint and Answer
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***** HINT *****
The patient denies any trauma after the cast was removed.
Detachment of the proximal nail was preceded by temporary arrest in growth of the nail, though the nail matrix was not directly damaged.
Pathologic examination of the vascular nodule reveals features of pyogenic granuloma.
Nerve conduction and electromyographic results are normal.
***** ANSWER *****
Paronychia and periungual pyogenic granuloma after cast immobilization: The history of pain and paresthesia of the hand during the period of immobilization suggests that the cast might have been too tight, causing mild peripheral nerve injury. However, the mechanism by which mild injury produces a pyogenic granuloma is unknown. This lesion is usually caused by minor wounds in the proximal nail fold.
Clinically, pyogenic granuloma may mimic nail tumors, including subungual squamous carcinoma and melanoma. About 20% of cases of nail melanoma are amelanotic.
Cast immobilization should be included among the possible causes of periungual pyogenic granuloma. When a patient complains of pain and paresthesia of the hand during or after immobilization, the possibility of nail damage due to an improperly applied cast should be considered.
For more information about paronychia and pyogenic granuloma, see the eMedicine articles Paronychia and Pyogenic Granuloma (Lobular Capillary Hemangioma).
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Author:
Antonella Tosti, MD, Director of Allergology, Associate Professor, Department of Dermatology, S. Orsola Hospital and University of Bologna; Stylianos Voudouris, MD, Fellow, Department of Dermatology, University of Bologna; Simona Tullo, MD, Fellow, Department of Dermatology, University of Bologna; Massimiliano Pazzaglia, MD, Fellow, Department of Dermatology, University of Bologna, Italy
University of Bologna, Department of Dermatology
eMedicine Editor:
William D. James, MD
Program Director, Vice-Chair, Albert M. Kligman Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Source
http://emedicine.com
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