Unravelling harpoon nail: Surgical outcome and insights

INTRODUCTION

An ingrown toenail (onychocryptosis) is a chronic and painful condition affecting adolescents. In a rare variant called “harpoon nail,” a sharp spike of the nail plate penetrates deep tissue, which results in inflammation and granulation tissue formation.¹ Such cases are rare in occurrence, and only a few are reported in India. The most common cause of the harpoon nail is improper cutting of the nail.² It typically affects the hallux, especially its outer edge, causing a nail spur that pierces surrounding soft tissues, which leads to channel formation.¹ Trauma, excessive sweating, and tight shoes can worsen this condition, as it compresses the nail fold against the nail plate. Sometimes, it can be complicated by secondary bacterial infection.³ Hereby, we describe a unique and rare variant of the distal lateral ingrowing toenail - the harpoon nail and its surgical management.

CASE REPORT

A 28-year-old Indian female presented with severe pain and swelling in the left hallux for 5 years. Her prior treatments included analgesics and local dressing. On examination, the distal nail plate was found to be covered with hypertrophic soft tissue, extending 3 mm beyond this tissue [Figures 1 and 2]. The patient showed no signs of infection, and pre-operative antibiotics were not administered. Only induration and a localized increase in temperature were observed on palpation. She was diagnosed with a harpoon nail due to both lateral and distal nail fold hypertrophy.

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Figure 1:

Dorsal view of the left hallux showing hypertrophic nail folds covering the distal nail plate.

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Figure 2:

Frontal view of the left hallux showing granulation tissue and extended nail plate distally.

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Surgical technique

The left forefoot was prepped and draped using betadine, and hemostasis was achieved with a rubber tourniquet. The nail surgery was performed under a proximal digital block, using 2% xylocaine infiltrated into the medial and lateral aspects of the left hallux. Initially, the hypertrophic tissue covering the nail plate was excised, and the underlying granulation tissue was removed with a nail spatula. Approximately 15% of the medial and lateral nail plates were resected using Adson’s forceps and scissors, followed by the application of the modified Winograd technique to excise the hypertrophic nail folds [Figure 3a and b]. The lateral horn of the matrix was ablated by radiocautery using a tungsten electrode that was flat and bent at an angle. The electrode was placed for 3–5 s and it was repeated 2–3 times. The remaining nail fold tissue was advanced to the nail plate and sutured with 4–0 ethilon bilaterally and distally [Figure 4]. The tourniquet was then removed, showing an immediate hyperemic response and prompt capillary refill distally. The soft tissue was granular without any pus or non-viable tissue. The patient was discharged with a short course of prophylactic antibiotics and analgesics. At the first follow-up visit a week later, the sutures were removed, and the nail unit showed minimal inflammation. Thus, a modified Winograd procedure with matricectomy using radiocautery was chosen for the surgical correction of this rare case.

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Figure 3:

(a) Diagrammatic representation of wedge resection of lateral nail folds in a harpoon nail and (b) dorsal view of left hallux after excision of nail plate and nail fold.

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Figure 4:

Immediate post-operative photograph after suturing of both lateral and distal folds.

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Results

The modified Winograd technique, along with radiocautery for matricectomy, effectively treated the rare harpoon nail variant of onychocryptosis. During regular follow-up visits, the patient reported no complaints about wearing shoes. After 2 years, the patient’s left hallux appeared normal and healthy, with proper alignment, no nail dystrophy, and satisfactory cosmetic results [Figure 5].

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Figure 5:

Post-operative photograph of the left hallux.

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DISCUSSION

This rare variant of onychocryptosis was first described by Richert (2014).⁴ They called it “a harpoon nail” because it looks like a marine hunting tool with a pointed tip and a broad base.⁴ It results from a vicious cycle of pain, edema, and faulty technique of nail clipping. When a patient tries to relieve pain from an ingrown nail by adjusting the side of the nail plate but cannot reach the outermost and deepest part of the nail plate, a lateral nail fragment can be left behind. This fragment then grows into a nail spicule, piercing through the surrounding tissue and creating a fistulous path that surfaces in the hyponychium.¹ In the acute stage, it manifests with erythematous, edematous swelling with oozing and crusting, and if left untreated, progresses to the chronic form, where the inflammation resolves and the epithelialization of the fistulous tract takes place.⁴

Onychocryptosis can be classified into different stages as described by Heifetz,⁵ Frost,⁶ Martinez Nova et al.,⁷ and Mozena,⁸ with some modifications among them. This rare variant, known as the Harpoon nail, is classified solely by Mozena as stage 4, characterized by hypertrophic tissue entirely covering the medial, lateral, and distal nail plate.⁸ However, this staging system does not account for the formation of unilateral spur, bilateral spur, or complete nail plate penetration from the distal hypertrophied nail fold.

We propose classifying the harpoon nail into three stages. This will help categorize the severity and guide appropriate treatment options for patients presenting with this rare condition [Figure 6].

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Figure 6:

Harpoon nail staging system.

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Surgery remains the primary treatment for harpoon nails.¹ The modified Winograd technique offers significant advantages over the traditional method, including precise curette removal of the germinal matrix and nail fold, followed by radiocautery. This approach is minimally invasive, quick, and highly effective, resulting in high patient satisfaction and low recurrence rates. In addition, it is preferred for its cosmetic benefits and minimal tissue damage.⁹ Other treatment options, such as the Vandenbos procedure, Zadik’s method, or the Super U technique, involve debulking all periungual soft tissues to expose the spicule. However, these alternatives tend to cause more tissue damage and require a longer healing time.^10,11

CONCLUSION

The excessive soft-tissue hypertrophy seen in harpoon nails can be successfully managed with the modified Winograd technique. This method yields high patient satisfaction by achieving both functional and cosmetically pleasing outcomes.