Congenital malalignment of the great toenails: A case report and review of treatment strategies

Abstract

Congenital malalignment of the great toenails (CMGT) is an underdiagnosed dystrophic disorder that affects 1-2% of children and is characterised by lateral deviation of the longitudinal axis of the nail plate in relation to the hallux. Affected nails are typically short and hyperkeratotic with transverse grooves or ridges, giving an oyster shelllike appearance. It commonly presents in infancy or childhood but may not be identified until the child is older or develops complications from repeated microtraumas to the toenail. Herein, we present a case of CMGT and summarise the existing literature on treatment strategies. An 11-year-old female presented with a 6-month history of abnormal and slowly growing great toenails. Examination revealed thickening, transverse ridging, yellow-brown discolouration, and lateral deviation of the great toenail plates. Fungal cultures of clippings from each great toenail were negative. The patient was diagnosed with CMGT based on history and morphologic appearance and was managed conservatively with podiatric care. Treatment options for CMGT depend on the severity of malalignment and range from conservative to surgical interventions. As spontaneous resolution and realignment of the nail may occur in 50% of cases, a conservative approach based on prevention and treatment of complications is recommended. Podiatry review for managing thickened nails, maintaining shorter toenail length, and prescribing appropriately fitting footwear is encouraged. Surgical intervention may be necessary for patients with severe deviation or complications, such as recurrent episodes of infection, and include realignment of the nail matrix, nail matrixectomy, ungueodermal flap repair, and surgical elongation of the extensor tendon of the phalanx. A correct diagnosis is required to prevent unnecessary investigations and treatments, and to reduce the occurrence of adverse treatment effects in children mistakenly treated for onychomycosis. Furthermore, early recognition and treatment of CMGT help prevent common complications such as onychocryptosis, bacterial infection, onychomycosis, and paronychia.L6381498922022-06-08 <br />