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Dorsomedial exostosis at the distal phalanx of hallux a cause of pain- A case report

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Abid Hussain Koka MS (Orthopaedics)
Senior resident
Department of Orthopaedics
SKIMS Medical College

Moulvi Sajad MS (Orthopaedics)
Senior resident
Department of Orthopaedics
SKIMS Medical College

Sohail Majid MS (orthopaedics)
Astt. Professor
Department of Orthopaedics
SKIMS Medical College

Naseer Ahmad Mir MS (Orthopaedics)
Astt. Professor
Department of Orthopaedics
SKIMS Medical College

Citation: A. H. Koka, M. Sajad, S. Majid & N. A. Mir : Dorsomedial exostosis at the distal phalanx of hallux a cause of pain- A case report. The Internet Journal of Orthopedic Surgery. 2009 Volume 13 Number 1

Case History
Discussion
Address for correspondence

Abstract

Pain at the medial aspect of great toe is often due to ingrowing toe nail, subungual or periungual pyogenic granuloma. Exostosis at the dorsomedial aspect of the distal phalanx can present with such symptoms and should be kept in the differential diagnosis. Good quality radiographs should be sought and exostosis looked for. We report the case of a 25 years old male with exostosis at the distal phalanx of hallux, who presented with pain at the medial aspect of his right great toe.

Case History

A 25 years old male presented to our hospital with pain at the medial aspect of his right great toe. He was already operated in another hospital, as his pain had been erroneously attributed to ingrowing toe nail after his pain did not improve with a trial of NSAID. Partial nail excision had been done. Later he had been treated on the lines of subungual pyogenic granuloma for his painful and inflamed nailbed. With the course of time acute inflammation had settled but his pain continued.

We took digital radiographs of his great toe (Fig. 1) that revealed a dorsomedial exostosis at the distal phalanx. Reviewing his initial radiographs (Fig. 2) showed a bony shadow at the distal phalanx which was missed at that time. Surgical excision of the exostosis was undertaken.

Figure 1

Discussion

Subungual exostosis is an acquired, benign bony tumor that can affect any age group but most often is discovered in persons 10 to 30 years of age with no gender or racial predilection. It presents as a distal, subungual mass or pain usually on the dorsal-medial great toe. Fingernail lesions rarely occur ¹. Subungual exostosis begins as a reactive fibrous growth that develops cartilage and ultimately ossifies ¹. A dorso-medial location is characteristic. Size of lesion is about 1 cm in diameter. Histologically it has a fibrocartilagenous cap on a base of trabecular bone. Great toe involved in 70-80% of cases ¹. Subungual/ dorsomedial exostosis should be kept in the differential diagnosis of pain at the nail bed or medial aspect of hallux. Although the diagnosis can be made with a biopsy, radiographs to evaluate for bony involvement are recommended before biopsy of any subungual mass is undertaken¹. This can prevent the wrong diagnosis and treatment. Exostosis at the hallux has also been reported after nail excision. Inadvertent iatrogenic injury to the nail bed and underlying phalangeal periosteum during nail removal may trigger off rapid bone growth resulting in exostosis ².

Exostosis at hallux can become symptomatic after surgical correction of hallux valgus³

Complete excision remains the treatment of choice, although recurrences are reported. Since the tumor can recur, some authors recommend that it is best to initially treat any subungual lesion aggressively by saucerization rather than simple exostectomy ⁴. They advocate to saucerize and curettage the lesion with a high-speed burr and pack the area with allogenic bone graft. By doing so no recurrence has been reported in their cases.

Address for correspondence

Abid Hussain Koka.
Flat no. 10. Govt. flats Jawaharnagar Srinagar,
Near SBI. J&K India Pin code 190001
Email: [abidkoka@yahoo.co.in]
Phone no. +91-9419080662

References

1. Marc S. Berger, M.D., C.M; Cry ungual. American family physician ,Volume 61, No. 1 ( Jan 1, 2000). (s)

2. B. Sankar , B.Y. Ng , P. Hopgood , A.J. Banks. Subungual exostosis following toe nail removal – case report. International journal of clinicalpractice, Volume 59, issue 147; page 132-133 (s)

3. C. Villas, J. Del Río, A. Valenti, M. Alfonso The Journal of Foot and Ankle Surgery, Volume 48, Issue 1, Pages 47-51 (s)

4. Al Kline, DPM, Subungual osteochondroma or Exostosis cartilaginea of the hallux – A case report of recurrent bone tumour one year after removal P. Podiatry Internet Journal 2 (2): (s)

This article was last modified on Wed, 13 May 09 18:31:46 -0500

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	The Internet Journal of Orthopedic Surgery™ ISSN: 1531-2968 \| Home \| Editors \| Current Issue \| Archives \| Instructions for Authors \| Disclaimer \| Share with others \| Dorsomedial exostosis at the distal phalanx of hallux a cause of pain- A case report Read printer friendly Subscribe in a reader Share with others Abid Hussain Koka MS (Orthopaedics) Senior resident Department of Orthopaedics SKIMS Medical College Moulvi Sajad MS (Orthopaedics) Senior resident Department of Orthopaedics SKIMS Medical College Sohail Majid MS (orthopaedics) Astt. Professor Department of Orthopaedics SKIMS Medical College Naseer Ahmad Mir MS (Orthopaedics) Astt. Professor Department of Orthopaedics SKIMS Medical College Citation: A. H. Koka, M. Sajad, S. Majid & N. A. Mir : Dorsomedial exostosis at the distal phalanx of hallux a cause of pain- A case report. The Internet Journal of Orthopedic Surgery. 2009 Volume 13 Number 1 Table of Contents Case History Discussion Address for correspondence Abstract Pain at the medial aspect of great toe is often due to ingrowing toe nail, subungual or periungual pyogenic granuloma. Exostosis at the dorsomedial aspect of the distal phalanx can present with such symptoms and should be kept in the differential diagnosis. Good quality radiographs should be sought and exostosis looked for. We report the case of a 25 years old male with exostosis at the distal phalanx of hallux, who presented with pain at the medial aspect of his right great toe. Case History A 25 years old male presented to our hospital with pain at the medial aspect of his right great toe. He was already operated in another hospital, as his pain had been erroneously attributed to ingrowing toe nail after his pain did not improve with a trial of NSAID. Partial nail excision had been done. Later he had been treated on the lines of subungual pyogenic granuloma for his painful and inflamed nailbed. With the course of time acute inflammation had settled but his pain continued. We took digital radiographs of his great toe (Fig. 1) that revealed a dorsomedial exostosis at the distal phalanx. Reviewing his initial radiographs (Fig. 2) showed a bony shadow at the distal phalanx which was missed at that time. Surgical excision of the exostosis was undertaken. Figure 1 Figure 1 Discussion Subungual exostosis is an acquired, benign bony tumor that can affect any age group but most often is discovered in persons 10 to 30 years of age with no gender or racial predilection. It presents as a distal, subungual mass or pain usually on the dorsal-medial great toe. Fingernail lesions rarely occur ¹. Subungual exostosis begins as a reactive fibrous growth that develops cartilage and ultimately ossifies ¹. A dorso-medial location is characteristic. Size of lesion is about 1 cm in diameter. Histologically it has a fibrocartilagenous cap on a base of trabecular bone. Great toe involved in 70-80% of cases ¹. Subungual/ dorsomedial exostosis should be kept in the differential diagnosis of pain at the nail bed or medial aspect of hallux. Although the diagnosis can be made with a biopsy, radiographs to evaluate for bony involvement are recommended before biopsy of any subungual mass is undertaken¹. This can prevent the wrong diagnosis and treatment. Exostosis at the hallux has also been reported after nail excision. Inadvertent iatrogenic injury to the nail bed and underlying phalangeal periosteum during nail removal may trigger off rapid bone growth resulting in exostosis ². Exostosis at hallux can become symptomatic after surgical correction of hallux valgus³ Complete excision remains the treatment of choice, although recurrences are reported. Since the tumor can recur, some authors recommend that it is best to initially treat any subungual lesion aggressively by saucerization rather than simple exostectomy ⁴. They advocate to saucerize and curettage the lesion with a high-speed burr and pack the area with allogenic bone graft. By doing so no recurrence has been reported in their cases. Address for correspondence Abid Hussain Koka. Flat no. 10. Govt. flats Jawaharnagar Srinagar, Near SBI. J&K India Pin code 190001 Email: [abidkoka@yahoo.co.in] Phone no. +91-9419080662 References 1. Marc S. Berger, M.D., C.M; Cry ungual. American family physician ,Volume 61, No. 1 ( Jan 1, 2000). (s) 2. B. Sankar , B.Y. Ng , P. Hopgood , A.J. Banks. Subungual exostosis following toe nail removal – case report. International journal of clinicalpractice, Volume 59, issue 147; page 132-133 (s) 3. C. Villas, J. Del Río, A. Valenti, M. Alfonso The Journal of Foot and Ankle Surgery, Volume 48, Issue 1, Pages 47-51 (s) 4. Al Kline, DPM, Subungual osteochondroma or Exostosis cartilaginea of the hallux – A case report of recurrent bone tumour one year after removal P. Podiatry Internet Journal 2 (2): (s) This article was last modified on Wed, 13 May 09 18:31:46 -0500 This page was generated on Thu, 02 Sep 10 23:23:09 -0500, and may be cached.
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