EDITORIAL-W. M. STEEL/R. W. HILES

Mr Steel is Consultant Orthopaedic Surgeon to the North Staliordshire Royal Inkmary and

Hsrtshill Orthopaedic Hospital, Stokwn-Trent. He is Chairman of the Specialist Advisory Committee in Orthopaedic Surgery and President of the British Society for Surgery of the Hand.

FORD, D. J., ALI, M. S. and STEEL, W. M. (1989). Fractures of the fifth metacarpal neck : is reduction or immobilisation necessary? Journal of Hand Surgery, 14B: 2: 165-167.

References ARAFA, M., HAINES, J., NOBLE, J. and CARDER, D. (1986). Immediate

mobilisation of fractures of the neck of the fifth metacarpal. Injury, 17: 4: 277-278.

0 1990 The British Society for Surgery of the Hand

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SUB-UNGUAL MELANOMA

Education is a fine thing but finest for improving diagnostic skills when the scholars are those doctors to whom patients first report. Hand surgeons’ patients are almost invariably secondary referrals and sometimes tertiary or more. Generations of specialists will have noted, since Sir Jonathan Hutchinson’s strictures in the British Medical Journal of 1886 (Vol. 1 page 491), that the diagnosis of subungual melanoma is “always missed in the early stages”. The “Melanotic Whitlow” has not changed, except perhaps to be recognised more often than not as the amelanotic whitlow. It is still mistaken for benign conditions, such as haematoma, inflammatory granuloma or simple naevus and the early treatment that will increase survival prospects and may improve the chances of cure is rarely achieved. We need another learned paper to draw our attention to the unimproved plight of sufferers from subungual melanoma and that by Hudson and others from South Africa in this issue does just that.

The writer was saddened a few years ago to be able to argue in Court, as a Defendant’s expert witness, that it was not negligent to miss a diagnosis of subungual melanoma for nine months, as 18 months was nearer the norm for the period from first presentation to definitive treatment. The patient had been seen by no less than six different doctors and only the last had followed the rule “assume all subungual lesions are melanoma until proved otherwise by biopsy”. In addition to the generally low awareness that a subungual lesion might be melanoma- tous, there is a natural reluctance to cut into the root or bed of the nail for fear of causing subsequent deformity, but this innate caution must be overcome when suspicion runs high. Moreover, the rarity of this malignancy perpetuates the unlearned lessons.

If only 13 subungual melanomas of the fingers are seen in a busy South African Melanoma Clinic in 18 years, how very rare it must be for a general practitioner, a casualty officer or even a manicurist to see one, let alone recognise one. Little wonder that the diagnosis is missed amongst a plethora of common benign conditions. We need to transmit the simple rule more effectively to those who send us patients if the general index of suspicion is

to be raised from a morbid procrastination to a life- saving galvanism.

Inevitably most published series of subungual melan- omata are small, so statistically significant deductions are therefore rare. Hudson and his colleagues stress the peculiarities of melanoma when it arises subungually but are understandably unable to say anything that is new. Their reinforcement of old lessons which remain un- learned is nevertheless valuable and the article is an important review of current knowledge of this sinister rarity.

A point of interest would have been the relationship of tumour progression to its thickness (Breslow) but unfor- tunately this analysis was not included in their paper. The keratin layer, epidermis and dermis of the nail are so specialised and so different from those of the rest of the skin that it is small wonder that subungual melanoma should be seen as a “site specific entity”. It seems likely that the difference in incidence, including racial factors, and the rapidity and pattern of spread of tumour developing there may hold a key to further knowledge of the fundamental mechanisms of tumour genesis and spread; to focus our interest and enquiry on these differences will be rewarding, Nowhere, except perhaps for the scalp, is there so much keratin shielding the epidermis from trauma and ultra-violet radiation, or so little melanin and such proximity of skin to bone. If it is true that for sub-ungual tumours site is more significant than the best prognostic factors yet recognised (namely absolute tumour thickness and relative dermal involve- ment), we need to study the peculiarities of this site in much greater detail.

Nevertheless the overwhelmingly important immedi- ate message is: Under the nail? Think melanoma, even if not black !

R. W. Jdiles

Mr. Hiles is Consultant Plastic Surgeon at Frenchay Hospital, Bristol and is Vice-President of

the British Society for Surgery of the Hand. He is also past- President of the British Association

of Plastic Surgeons and is on the Council of the Medical Defeoce Union.

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280 THE JOURNAL OF HAND SURGERY