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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5765_Библиотеки_им_академика_М_И_Перельмана.pdf
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8 Ultrasound ofNail Conditions
c
d
Fig. 8.5 (continued)
a
8.1 Growth andLocation Alterations
223
b
Fig. 8.6 Retronychia. (a) Clinical photograph of the right index nger.
(b) Greyscale ultrasound (longitudinal views; side-by-side comparative
views of the right and left index nger) demonstrates decreased distance between the origin of the nail plate and the base of the distal
phalanx, as well as thickening and decreased echogenicity of the proximal nail fold in the right index. Notice the thin hypoechoic halo surrounding the origin of the proximal nail plate at the right side.
224
8 Ultrasound ofNail Conditions
8.2 Congenital Diseases
8.2.1 Malalignment
8.2.1.1 Denition
Abnormal longitudinal axis of growth of the nail plate, usually with lateral deviation. It can be unilateral or bilateral and
most commonly affects the big toenail. Acquired and
iatrogenic malalignments have been reported, most of them
probably related to a chronic trauma of the nail matrix.
a
8.2.1.2 Key Sonographic Signs
• Thickening and decreased echogenicity of the nail
bed that affects the nail matrix region (Fig.8.7)
• Thickening and loss of the bilaminar pattern of the nail
plate that can be associated with fragmentation of part of
the ventral plate.
• Secondary onychocryptosis may be present [1, 2]
b
Fig. 8.7 Congenital malalignment. (a) Clinical photograph of the right
big toenail (notice the lateral deviation of the nail). (b) Greyscale ultrasound (longitudinal view) shows decreased echogenicity and thicken-
ing of the nail bed. Notice the thickening of the nail plate and some
hyperechoic linear fragments of the nail plate in the nail bed close and
attached to the ventral plate.
8.2 Congenital Diseasesv
225
8.2.2 Cystic Fibrosis
8.2.2.1 Denition
Autosomal recessive disease resulting from mutations in the
cystic brosis transmembrane conductance regulator gene. The
main clinical manifestations are related to lung disease, pancreatic insufciency, and infertility, but skin and nail abnormalities can be present. Patients commonly show digital clubbing.
a
8.2.2.2 Key Sonographic Signs
• Increased convexity of the nail plate
• Increased thickness and decreased echogenicity of the
nail bed
• Prominent hypervascularity in the nail bed (Fig. 8.8;
Video8.4) [7, 8]
b
Fig. 8.8 Cystic brosis. (a) Clinical photograph of the right thumb. Notice the digital clubbing. (b) Color Doppler ultrasound (longitudinal view;
right thumb) shows increased convexity of the nail plate and prominent hypervascularity (colors) in the nail bed. Video8.4.
226
8 Ultrasound ofNail Conditions
8.3 Inammatory Conditions oftheNail
8.3.1 Psoriasis
8.3.1.1 Denition
Chronic autoimmune disease that commonly generates erythematous and scaly patches on the skin. This condition can
affect the nails, tendons, entheses, joints, and bony margins.
According to literature, of psoriatic patients with nail
involvement, 5% do not show cutaneous effects; of patients
with psoriatic arthritis, 53–86% commonly present with nail
involvement [9–12].
thickening of the nail bed
hyperechoic deposit
in the ventral plaque
thickening of ventral
and dorsal plaque
wavy plaques
Fig. 8.9 Nail psoriasis. Greyscale (longitudinal views) sonographic signs of psoriatic onychopathy.
8.3 Inammatory Conditions oftheNail
227
Fig. 8.10 Nail psoriasis. 3D ultrasound reconstructions (longitudinal views) showing sonographic signs of psoriatic onychopathy.
228
8 Ultrasound ofNail Conditions
a
b
Fig. 8.11 Nail psoriasis. (a)Clinical photograph of the right middle
nger. (b) Greyscale ultrasound (longitudinal view; right middle nger)
demonstrates thickening and decreased echogenicity of the nail bed.
Notice the hyperechoic deposit at the distal edge of the ventral plaque
(arrow) and the loss of denition of the ventral plate (arrowhead).
8.3 Inammatory Conditions oftheNail
a
b
229
c
Fig. 8.12 Nail psoriasis. (a) Clinical photograph of the right ring n-
ger. (b) Greyscale ultrasound (longitudinal panoramic view; right ring
nger, dorsal region) demonstrates focal areas of epidermal and dermal
thickening and decreased echogenicity of the upper dermis, corresponding to the location of the cutaneous plaques. There is decreased
echogenicity (asterisk) of the lower dermis and the hypodermis neighboring the proximal interphalangeal joint (pip). (c) Color Doppler ultrasound (longitudinal view; right ring nger) shows increased thickness
and decreased echogenicity of the nail bed as well as slight undulation
of the nail plate (arrow). dip distal interphalangeal joint. Video 8.5.
230
8 Ultrasound ofNail Conditions
a
b
Fig. 8.13 Nail psoriasis. (a) Clinical photograph of the right thumb.
(b) Ultrasound (Greyscale, longitudinal view) shows thickening of the
nail bed, loss of denition of the ventral plate (arrowhead), and hyper-
echoic deposit (arrow) in the distal part of the ventral plate. (c) Color
Doppler ultrasound demonstrates increased blood ow in the proximal
part of the nail bed.
8.3 Inammatory Conditions oftheNail
c
Fig. 8.13 (continued)
231
8.3.1.2 Key Sonographic Signs
The following ultrasonographic signs show variable degrees
of involvement of the nail from early to late stages; however,
these or part of these signs could appear concomitantly in the
same nail. Besides, the ngernails and toenails of the same
patient can differ in their degree of affection. Moreover, the
sonographic signs of nail involvement in psoriasis can vary
over time according to the progression of the disease and the
treatment of the patient. The following includes the most
commonly found sonographic signs (Figs. 8.9, 8.10, 8.11,
8.12, and 8.13; Video 8.5) [1, 2, 9–12]:
• Thickening of the nail bed (increased distance between the
ventral plate and the bony margin of the distal phalanx)
• Loss of denition of the ventral plate
• Hyperechoic focal involvement of the ventral plate (can
be subclinical)
• Thickening, irregularities, and undulation of one or both
nail plates, commonly in late phases
• Increased blood ow in the nail bed (sign of activity):
tends to affect the proximal nail bed
– Total involvement of the nail bed: Hypervascularity
affects the whole nail bed.