5/20/2014 Nail Anatomy

http://emedicine.medscape.com/article/1948841-overview 1/9
Nail Anatomy
Author: Benjamin Z Phillips, MD, MPH; Chief Editor: Thomas R Gest, PhD more...

Updated: Sep 12, 2013
Overview
The nail organ is an integral component of the digital tip. It is a highly versatile tool that protects the fingertip,
contributes to tactile sensation by acting as a counterforce to the fingertip pad, and aids in peripheral
thermoregulation via glomus bodies in the nail bed and matrix.
[1, 2]
Because of its form and functionality,
abnormalities of the nail unit result in functional and cosmetic issues. The structures that define and produce the
nail (nail plate) include the matrix (sterile and germinal), the proximal nail fold, the eponychium, the paronychium,
and the hyponychium (see the images below). Collectively, the nail bed (sterile matrix), nail fold, eponychium,
paronychium, and hyponychium are referred to as the perionychium.
Nail surf ace anatomy.
Nail anatomy.
Gross Anatomy
The nail plate emerges from the proximal nail fold and is bordered on either side by the lateral nail folds
(paronychium). The nail plate is composed of hard, keratinized, squamous cells that are loosely adherent to
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germinal matrix but strongly attached to the sterile matrix.
[2]
The nail fold, the most proximal aspect of the
perionychium, is composed of a dorsal roof and a ventral floor. It is found approximately 15 mm distal to the distal
interphalangeal joint (DIP).
[3, 4]
The dorsal roof rests above the forming nail, and the ventral floor lies beneath the nail, immediately distal to the
insertion of the extensor tendons. The ventral floor is the site of the germinal matrix and is responsible for 90% of
nail production. The dorsal roof of the nail fold plays a role in housing cells that impart shine to the nail. The skin
proximal to the nail that covers the nail fold is the eponychium. The tissue distal to the eponychium in contact with
the nail represents the cuticle.
Extending from proximal to distal on the nail is a half-moon shaped white arc known as the lunula (see the image
below). The lunula is the distal extent of the germinal matrix.
[4]
This characteristic color change is due to the
persistence of nail cell nuclei in the germinal matrix; distal to this location, nuclei are absent, and the nail is
transparent.
[2]
The area of the nail bed distal to the lunula is the sterile matrix. This is a secondary site of nail
production and is tightly adherent to the nail plate and the periosteum of the distal phalanx.
Nail surf ace anatomy.
A junction is formed between the sterile matrix and the fingertip skin beneath the nail margin. This area is referred
to as the hyponychium. This region is susceptible to contamination from environmental interactions. A keratin plug
acts as a mechanical barrier to protect against infectious inoculation. Also found within this keratin plug are
polymorphonuclear leukocytes and lymphocytes contributing an immunologic barrier to the mechanical one
established by the keratin plug.
[2]
The arterial blood supply to the perionychium originates from the terminal branches of the radial and ulnar proper
palmar (volar) digital arteries. These vessels originate proximal to the metacarpophalangeal joint from the common
palmar digital arteries. The proper palmar digital arteries branch proximal to the DIP joint and give off a branch that
travels dorsal to the DIP joint, supplying the superficial arcade that feeds the nail fold and proximal matrix.
[3]
Nail Growth
Development of the nail matrix begins in the ninth embryonic week from the nail anlagen. By week 16, the fetal nail
is identifiable.
[1]
Nearly 90% of the nail plate is produced by the proximal half of the matrix, more specifically, the
germinal matrix. As a result, more of the nail plate substance is produced proximally, leading to a natural convex
curvature of the nail from proximal to distal. Ulnar and radial projections of the matrix extend proximally to form
points or horns of the matrix (see the image below).
[3]
These lateral horns are attached to the dorsal expansion of
the lateral ligament of the distal interphalangeal joint (DIP).
[1]
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Nail matrix horns.
Nail growth is separated into 3 areas: (1) germinal matrix, (2) sterile matrix, and (3) dorsal roof of the nail fold.
The germinal matrix has the following characteristics:
It is found on the ventral floor of the nail fold; The nail is produced by gradient parakeratosis
Cells near the periosteum of the phalanx duplicate and enlarge (macrocytosis)
Newly formed cells migrate distally and dorsally in a column toward the nail
Cells meet resistance at established nail, causing them to flatten and elongate as they are incorporated
into the nail
It initially retains nuclei (lunula); more distal cells become nonviable and lose nuclei
The sterile matrix has the following characteristics:
The area is distal to the lunula
It has a variable amount of nail growth.
It contributes squamous cells, aiding in nail strength and thickness
It has a role in nail plate adherence by linear ridges in the sterile matrix epithelium
The dorsal roof of the nail fold has the following characteristics:
The nail is produced in a similar manner as the germinal matrix
The cells lose nuclei more rapidly
It imparts shine to the nail plate
Nail growth is estimated at 3-4 mm per month. Complete nail plate growth takes approximately 6 months. Certain
factors increase the rate of the growth. These include longer digits, summer months, young persons (< 30 y), and
nail biters.
[2]
Fingernail Pathology
Abnormalities of the nail plate can be classified according to whether they are morphologic or related to nail color.
These changes can be associated with systemic disease and provide an early clue to practitioners.
[5, 6]
Below are
examples of nail plate changes and the associated disease processes that they represent.
Onycholysis
On examination, onycholytic nails are smooth and firm, and there is distal separation of the nail plate from the nail
bed. Onycholysis is associated with the following conditions:
Trauma, as seen in the following image
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Traumatic onycholysis.
Thyroid disease (especially hyperthyroid)
Plummer's nail: Onycholysis of fourth or fifth nail associated with hyperthyroidism
Anemia
Erythropoietic porphyria
Histiocytosis X
Peripheral ischemia
Leprosy
Lupus erythematosus
Pemphigus vulgaris
Porphyria cutanea tarda
Pellagra
Pleural effusion
Psoriatic arthritis
Reiter syndrome
Scleroderma
Syphilis
Aspergillus niger
[7]
Clubbing
Nails with clubbing have the following features:
Increased transverse and longitudinal nail curvature
Fibrovascular hyperplasia of paronychium
Lovibond angle (angle between dorsal surface of distal phalanx and the nail plate) is greater than 180 (see
the image below)
Lovibond angle.
Schamroth sign, which is a disappearance of the diamond shape created when the dorsal surfaces of
thumb interphalangeal joints are opposed (see the following image)
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Lef t: Normal space between opposing thumbs. Right: The window is lost with nail clubbing.
Clubbing is associated with the following conditions:
Hemiplegia (when unilateral)
Lung disease
Inflammatory bowel disease
Cardiovascular disease
Liver disease
Acquired immunodeficiency syndrome (AIDS)
Koilonychia
On examination, koilonychia findings include concavity of the nail plate and the appearance that a drop of water
could be retained in the nail (see the following image).
Koilonychia.
Koilonychia is associated with the following conditions:
Trauma
Iron deficiency anemia
Exposure to petroleum-based solvents
Hemochromatosis
Hypothyroidism
Coronary artery disease
Normal variant in infants
Koilonychia.
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Onychomadesis
A proximal separation of the nail plate is the characteristic finding in onychomadesis (see the image below).
Onychomadesis.
Onychomadesis is associated with the following conditions:
Trauma
Malnutrition
Drug sensitivity
Pemphigus vulgaris
Kawasaki disease (see the Kawasaki Disease Diagnostic Criteria calculator)
Hand, foot, and mouth disease
Beau lines
Beau line findings include a transverse depression in the nail plate secondary to temporary cessation of nail
growth, as seen in the following image. Beau lines are associated with high fever, malnutrition, and poorly
controlled diabetes.
Beau lines.
Muehrcke nails
Muehrcke nails include the following features (see the image below):
Transverse white bands parallel to the lunula
Usually found in pairs and traverse the entire nail
Form of leukonychia caused by abnormality in nail bed vasculature
Muehrcke nails.
Muehrcke nails are associated with the following conditions:
Hypoalbuminemia
Nephrotic syndrome
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Glomerulonephritis
Liver disease
Malnutrition
Post chemotherapy
Peutz-Jeghers syndrome
Lindsay nails
Findings on examination of Lindsay nails are as follows (see the following image):
Proximal nail bed is white secondary to edema
Distal nail bed pink or brown
Abnormal melanin pigment
Form of leukonychia caused by abnormality in nail bed vasculature
Lindsay nail (half -and-half nail).
Lindsay nails are associated with the following conditions:
Renal disease (hemodialysis patients)
Renal transplant
Human immunodeficiency virus (HIV)
Terry nails
Terry nails demonstrate the following findings (see the image below):
Most of the nail plate is white with a distal pink band
All nails are affected equally
The form of leukonychia is caused by abnormality in nail bed vasculature
Terry nail.
Terry nails are associated with the following conditions:
Cirrhosis
Chronic congestive heart failure (CHF)
Adult-onset diabetes mellitus
HIV
Red lunula
A red lunula is as its name describes (see the following image). In addition, the lunula may be absent, or an azure
(blue) lunula may be seen.
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Red lunula.
Red lunula is associated with the following conditions:
Alopecia areata
Collagen vascular disease
Prednisone use
Cardiac failure
COPD
Cirrhosis
Psoriasis
Carbon dioxide poisoning
Wilson disease (azure lunula)
5-fluouracil (5-FU) use (azure lunula)
Splinter hemorrhage
A splinter hemorrhage is a longitudinal extravasation of blood along the nail bed (see the image below).
Splinter hemorrhage.
Splinter hemorrhage is associated with the following conditions:
Bacterial endocarditis
Trauma
Mitral stenosis
Vasculitis
Cirrhosis
Scurvy
Chronic glomerulonephritis
Darier disease

Contributor Information and Disclosures
Author
Benjamin Z Phillips, MD, MPH Hand and Microsurgery Fellow, Department of Plastic and Reconstructive
Surgery, Washington University
Benjamin Z Phillips, MD, MPH is a member of the following medical societies: American College of Surgeons,
5/20/2014 Nail Anatomy
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Medscape Reference 2011 WebMD, LLC

American Public Health Association, American Society of Plastic Surgeons, and Rhode Island Medical Society
Disclosure: Nothing to disclose.
Coauthor(s)
Reena A Bhatt, MD Attending Physician, Clinical Assistant Professor of Surgery, Department of Plastic
Surgery, The Warren Alpert Medical School of Brown University
Reena A Bhatt, MD is a member of the following medical societies: American Association for Hand Surgery,
American Society for Surgery of the Hand, and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.
Scott T Schmidt, MD Clinical Assistant Professor, Department of Surgery, The Warren Alpert Medical School
of Brown University; Director of Hand Surgery, Assistant Program Director, Director of Microsurgical Resident
Training Lab, Department of Plastic Surgery, Rhode Island Hospital
Disclosure: Nothing to disclose.
Chief Editor
Thomas R Gest, PhD Professor of Anatomy, Department of Radiology, University of South Florida Morsani
College of Medicine
Disclosure: Lippincott Williams & Wilkins Royalty Other
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2012;85(8):779-87. [Medline].
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