Subungual exostosis of the toes: a systematic review

Nail dystrophy for the surgeon

Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.

Fibro-Osseus Pseudotumor of the Digit: A Case Report and Review of Literature

Introduction

Bony subungual growths arising on the digital tip are uncommon. Among these, subungual exostosis is a common cause.

Case Presentation

We describe a 35-year-old-male patient with a rare occurrence of a fibro-osseus pseudotumor of the digit. It presents with reactive intramembranous ossification, with no continuity with the distal phalanx, helping differentiate it from a subungual exostosis. The patient presented with an asymptomatic subungual growth, lifting up the nail plate distally causing onycholysis. The characteristic clinical, radiological, and histopathological features of the case are described, which helped confirm the diagnosis.

Conclusion

Cases with fibro-osseus pseudotumor of the digit reported in literature are reviewed comprehensively. The factors helping differentiate this from the other bony tumors affecting the distal phalanx, including subungual exostosis, myositis ossificans, and osteosarcoma are also highlighted.

The Influence of Clinical Factors on Treatment Outcome and a Recurrence of Surgically Removed Protruded Subungual Osteochondroma and Subungual Exostosis

BACKGROUND

Subungual exostosis (SE) and subungual osteochondroma (SO) are benign solitary lesions that grow from the distal phalanx. The mass itself is typically painless, but pressure on the nail plate can result in pain and deformity of the involved digit. Tumors can be correctly diagnosed based on clinical, histological and radiographic appearance alone. Surgical resection of SE/SO is typically curative, with a small risk of recurrence.

METHODS

The study was retrospective and observational, involving 74 patients with subungual SE/SO. The surgical procedure consisted of the removal of the tumor from the dorsal approach under digital anesthesia. The procedure was assessed using a questionnaire and photo documentation after a minimum of 6 months after surgery.

RESULTS

A total of 85% of respondents were satisfied with the procedure. Nearly 80% of patients rated the cosmetic effect as good or very good. Young age and pain intensity after surgery showed statistically significant associations with worse satisfaction. Age < 18 was associated with recurrence.

CONCLUSIONS

Worse satisfaction is strongly associated with recurrence. Gender, duration of symptoms, pain before surgery and tumor size and destruction of the nail plate had no significant effect on recurrence. The technique using burr appeared to be a more effective treatment.

Is Insulin Receptor Substrate4 (IRS4) a Platform Involved in the Activation of Several Oncogenes?

The IRS (insulin receptor substrate) family of scaffold proteins includes insulin receptor substrate-4 (IRS4), which is expressed only in a few cell lines, including human kidney, brain, liver, and thymus and some cell lines. Its N-terminus carries a phosphotyrosine-binding (PTB) domain and a pleckstrin homology domain (PH), which distinguishes it as a member of this family. In this paper, we collected data about the molecular mechanisms that explain the relevance of IRS4 in the development of cancer and identify IRS4 differences that distinguish it from IRS1 and IRS2. Search engines and different databases, such as PubMed, UniProt, ENSEMBL and SCANSITE 4.0, were used. We used the name of the protein that it encodes "(IRS-4 or IRS4)", or the combination of these terms with the word "(cancer)" or "(human)", for searches. Terms related to specific tumor pathologies ("breast", "ovary", "colon", "lung", "lymphoma", etc.) were also used. Despite the lack of knowledge on IRS4, it has been reported that some cancers and benign tumors are characterized by high levels of IRS-4 expression. Specifically, the role of IRS-4 in different types of digestive tract neoplasms, gynecological tumors, lung cancers, melanomas, hematological tumors, and other less common types of cancers has been shown. IRS4 differs from IRS1 and IRS2 in that can activate several oncogenes that regulate the PI3K/Akt cascade, such as BRK and FER, which are characterized by tyrosine kinase-like activity without regulation via extracellular ligands. In addition, IRS4 can activate the CRKL oncogene, which is an adapter protein that regulates the MAP kinase cascade. Knowledge of the role played by IRS4 in cancers at the molecular level, specifically as a platform for oncogenes, may enable the identification and validation of new therapeutic targets.

A Solitary, Large Calcaneal Osteochondroma Growing Extensively After Skeletal Maturity: A Case Report and Review of the Literature

Although osteochondromas are the most common benign tumors in the skeleton, calcaneal osteochondromas are very rare. New onset of pain or rapid growth of the tumor, especially after the closure of the epiphyseal growth plate, might reflect malignant transformation. However, enlargement of solitary osteochondromas reported as benign in a skeletally mature patient is present in the literature. We report the clinical and radiologic findings of a calcaneal osteochondroma with an extremely rare placement and painful rapid growth causing limited ambulation in a 27-year-old male. After surgical removal of the tumor, histologic examination demonstrated no evidence of malignancy, and there was no recurrence during the three-year follow-up.

Diagnosis and surgical treatment of benign nail unit tumors

Little is known about benign non-melanocytic nail tumors, probably due to their low pathogenicity. They are commonly misdiagnosed as inflammatory or infective diseases. They have various features, depending on the type of tumor and its location in the nail apparatus. The typical sign of a tumor is the presence of a mass and/or secondary nail changes from damaged nail structures. In particular, if a single digit is affected by a dystrophic sign or a symptom is reported without any explanation, the presence of a tumor should always be ruled out. Dermatoscopy helps to enhance visualization of the condition and in many cases supports the diagnosis. It may also assist in identifying the right place to biopsy, but it never replaces surgery. Most common non-melanocytic nail tumors are analyzed in this paper, including glomus tumor, exostosis, myxoid pseudocyst, acquired fibrokeratoma, onychopapilloma, onychomatricoma, superficial acral fibromyxoma and subungual keratoacanthoma. The aim of our study is to review the main clinical and dermatoscopic characteristics of the most common benign non-melanocytic nail tumors, to correlate them with the histopathology and to advise practitioners of the best surgical management.

Subungual Exostosis Presenting as a Pyogenic Granuloma-like Lesion with Reactive Myofibroblastic Proliferation in Two Young Women

Subungual exostosis (SE) is a well-recognised benign proliferation of the distal phalanx most often seen in young adults and affecting the big toe. Possible triggers include previous trauma and chronic irritation or infection. We describe two atypical cases of SE in two young women presenting with pyogenic granuloma-like lesions clinically. Diagnostic biopsies were performed to confirm the diagnosis and excluded amelanotic melanoma. However, histology unexpectedly revealed reactive myofibroblastic proliferations mimicking nodular fasciitis overlying the SE. Given the atypical clinical presentation, the diagnosis was initially missed or not considered in both patients. They highlight two important points; the first is that SEs may present with pyogenic granuloma-like lesions clinically and that histological analysis is then required to exclude malignancy, particularly amelanotic melanoma. Secondly, that the histology will show a reactive myofibroblastic proliferation and if the sample is relatively superficial and pathologists are not aware of this potential reaction pattern, the underlying diagnosis of SE may be missed.

Clinical diagnosis and treatment of subungual exostosis in children

OBJECTIVE

To analyze and summarize the clinical characteristics and treatment effects for subungual exostosis in children.

METHODS

Clinical data for children with subungual exostosis treated in our department from January 2008 to September 2022 were evaluated.

RESULTS

Forty children with subungual exostosis were evaluated, comprising 31 boys (77.5%) and 9 girls (22.5%) with a median age of 9 years (4-17 years). The median disease course was 6 months (1-48 months). Seven patients (17.5%) had definite trauma history and 5 (12.5%) had infection. The toe or finger nail appearance was abnormal in 36 patients and normal in 4 patients. Twenty-seven patients (67.5%) had pain when wearing shoes and walking, and 25 (62.5%) had toenail tenderness. The lesions were located in the distal phalanxes of the toes in 37 patients (92.5%), with 14 patients affected on the left side and 23 on the right side. Twenty-two patients had lesions in the great toe, 6 in the second toe, 6 in the third toe, and 3 in the fourth toe. The lesions in the other 3 patients (7.5%) were located in the distal phalanxes of the fingers, with 2 patients affected in the second finger and 1 in the third finger. Regarding the relationship between lesion location and nail bed, 4 patients were type I, 21 were type II, and 15 were type III. All 40 patients received surgical treatment, with nail removal in 15. The median maximum lesion diameter was 1.0 cm (0.8-2 cm), median operation time was 25 min (20-45 min), median blood loss was 1 ml (1-2 ml), and median postoperative hospital stay was 2 days (1-4 days). All cases were histopathologically confirmed as subungual exostosis. The median follow-up time was 24 months (3-60 months), with normal appearance of the toe or finger nail. There were no complications in 38 patients (95.0%). Two patients (5.0%) relapsed at 3 months postoperatively and underwent a secondary operation, with no subsequent recurrence during 12 months of follow-up.

CONCLUSION

Subungual exostosis in children is a rare benign disease that often occurs in the toes. Selection of the appropriate incision and nail bed treatment based on the relationship between lesion location and nail bed is helpful for improving the treatment effect.

Subungual Exostosis on the Right Hallux

Subungual exostosis (SE) is a benign, relatively uncommon bony growth underneath the nails of the distal phalanx of toes or fingers, with a majority on the toes. Clinically, it has two subvariants-protruded and nonprotruded growths from nail plates-which are treated differently. In this article, we report a case of protruded SE in a teenager with illustrative surgical excision. A 15-year-old boy presented with a painful growth on his right great toe of 6 months' duration. Physical examination revealed a 1-cm-diameter, solid, erythematous, rough, irregular growth penetrating through the skin along the dorsolateral nail bed of the right hallux with deformity of the lateral nail plate. Radiographs showed an elevated mass over the distal phalanx of the right lateral hallux. The mass was surgically excised and histopathologic examination confirmed the diagnosis of SE. The patient had no relapse or recurrence at follow-ups of 6 and 18 months. Subungual exostosis is a relatively uncommon bony growth in the toes. Radiography is favored for the diagnosis. Complete surgical excision is the optimal treatment, with rare recurrence. It needs to be differentiated from other bony lesions, including bizarre parosteal osteochondromatous proliferation, myositis ossificans, fibro-osseous pseudotumor, osteochondroma, and enchondroma.

Subungual Exostosis: A Case Series of 48 Patients

Background

Subungual exostosis is an unusual benign nail tumor, mostly located on the big toe. It generally affects young people and manifests as uncomfort during footwear.

Method

A monocentric retrospective study was conducted at the outpatient consultation for nail disorders at the Department of Dermatology of the University of Casablanca, Casablanca, Morocco, between April 2006 and October 2019.

Results

We diagnosed subungual exostosis in 48 patients, including 25 men and 23 women, with an average age of 20 years. The subungual exostosis was located on the hallux in 34 cases, the second toe in 10 cases, and the index finger in 2 cases. Nail trauma was found in 27 patients. The tumor was entirely excised in all the patients.

Conclusion

Large series of subungual exostosis are reported by orthopedic surgeons. However, our outpatient consultation for nail disorders allowed the diagnosis and appropriate management of subungual exostosis.

A Subungual Exostosis Mimicking a Periungual Granuloma in a 9-Year-Old Boy: An Unexpected Dermoscopic Pattern

Subungual exostosis (SE) is an uncommon osteocartilaginous tumor. Classic dermoscopic features of SE include vascular ectasia, hyperkeratosis, onycholysis, and ulceration. In this case, a 9-year-old boy presented SE showing a dermoscopic mesh dilated blood vessel pattern surrounded by a scar-like peripheral ring, which represents a novel finding in the medical literature.

Fibro-Osseous Pseudotumor

Fibro-osseous pseudotumor is an extremely rare subcutaneous benign ossifying lesion associated with bone formation that is most commonly seen in the hands, followed by the toes. Because the tumor has a certain degree of invasiveness, it is often mistaken for malignancy, which leads to radical, excessive treatment. Our case involved a 32-year-old man with lesions on the left index finger. We documented the detailed data of diagnosis, treatment, and follow-up. We also conducted a review and summarized the published cases to advance our understanding of the disease, provide more accurate diagnostic criteria, and avoid inappropriate surgical procedures. [Orthopedics. 2021;44(6):e713-e718.].

Ultrasound in Sports and Occupational Dermatology

Chronic exposure to trauma, friction, or extreme conditions can generate cutaneous or ungual lesions in sports and certain occupations. Although some of these dermatologic conditions are diagnosed with a naked-eye examination, there are cases in which the provision of the underlying anatomic alterations can be helpful for the diagnosis and management. In comparison with computed tomography or magnetic resonance imaging, ultrasound has the highest axial resolution, which is critical for the observation of anatomic changes in the skin and nail. We review the ultrasound characteristics of frequent cutaneous and ungual lesions related to sports and occupations with a clinical correlation. The ultrasound features in some particular conditions such as "biker's and surfer's panniculitis," "fiddler's neck," piezogenic papules, and lipoatrophy semicircularis, among others, are discussed.

Non-subungual presentation of osteochondroma in toes-A case report with review of literature

A 23-year-old male presented with long-standing swelling in the middle of the third toe right side with difficulty in wearing footwear. Clinical examination revealed it as bony hard fixed swelling moving with interphalangeal joint movements. Clinical diagnosis of benign bony swelling was made and radiological investigation demonstrated features suggestive of osteochondroma. En-mass excision of the lesion was done, with histo-pathological confirmation of osteochondroma. Although the subungual presentation of osteochondroma or exostosis in toes is quite common, the astounding non-subungual presentation should also be kept in mind as a plausible differential diagnosis of benign bony swelling in toes.

Neurothekeoma: Another differential in the diagnosis of a subungual swelling

CASE

Lesions, which commonly grow and protrude beneath the distal end of a toe nail and present to the podiatrist or foot and ankle surgeon, include subungual exostosis or enchondroma and a Nora lesion. Neurothekeoma is a benign dermal tumour of the peripheral nerve sheath that usually affects the skin of the head, neck, shoulders and arms. It occurs less commonly in the lower limbs and has only been reported twice in a subungual location. A case of subungual neurothekeoma that recurred twice due to inadequate margins of resection is presented.

CONCLUSION

Although rare, neurothekeoma should be included in the differential diagnosis of a subungual lesion. Histopathological diagnosis is reached by differential immunostaining. Adequate clear margins of resection are recommended to prevent recurrence.

Some Reactive Lesions of Bone Are Probably Neoplasms: A Review

CONTEXT.—

A number of fibro-osseous and osteocartilaginous lesions, especially common in the small bones of hand and feet, pose a diagnostic challenge and have historically been thought to be reactive lesions. However, modern molecular techniques when supplementing clinical, radiographic, and histologic evaluation suggest they may, in fact, be neoplasms.

OBJECTIVE.—

To review the clinical presentation and histopathologic, molecular, and radiologic features of selective bone lesions, focusing most specifically on subungual exostosis, florid reactive periostitis, and bizarre periosteal osteochondromatous proliferation.

DATA SOURCES.—

Literature review and personal experience are the source of this review.

CONCLUSIONS.—

Some lesions previously thought to be reactive are locally aggressive and demonstrate reproducible molecular abnormalities, and thus may be neoplasms. Although most common in the bones of the fingers and toes, these lesions also occur in long and other bones. The clinical presentations, radiologic appearances, and histopathologic features often overlap, making the diagnosis challenging, and these lesions may require molecular evaluation to maximize accurate prognostication.

A Comparative Study of Nail Fold Approach and Microscopic Nail Bed Approach in the Surgical Treatment of Subungual Exostosis

ABSTRACT

Subungual exostosis is a benign tumor that occurs under the nail plate of the distal phalanx and causes nail deformity and pain. There are many reports of recurrence and postoperative nail deformity, and the surgical approach needs to be reassessed. Two typical surgical approaches are from the nail fold and the nail bed. Here, we compare 2 surgical approaches for subungual exostosis that were performed in our department. Twenty-three cases of subungual exostosis were treated between 2010 and 2019; 12 cases were treated by the nail fold approach and 11 by the microscopic nail bed approach. The nail fold approach resulted in not only scarring but also nail deformities, such as onychodystrophy. There were 2 (18.2%) cases of recurrence. In the microscopic nail bed approach, there was no case of recurrence. It was possible to preserve the thinned nail bed by dissecting under a microscope, and the thinned nail bed did not become necrotic in any cases. To solve postoperative nail deformity and a high recurrence rate, sufficient resection and meticulous surgical procedure on the nail bed and nail matrix are essential. The microscopic nail bed approach satisfied both of these criteria and was considered to be a useful method for subungual exostosis.

Imaging Features of Primary Tumors of the Hand

Musculoskeletal tumors of the hand are a rare entity and are divided into skeletal and soft tissue tumors. Either category comprises benign and malignant or even intermediate tumors. Basic radiology allows an optimal resolution of bone and related soft tissue areas, ultrasound and more sophisticated radiologic tools such as scintigraphy, CT and MRI allow a more accurate evaluation of tumor extent. Enchondroma is the most common benign tumor affecting bone, whereas chondrosarcoma is the most commonly represented malignant neoplasm localized to hand bones. In the soft tissues, ganglions are the most common benign tumors and epithelioid sarcoma is the most frequently represented malignant tumor targeting hand soft tissues. The knowledge regarding diagnostic and therapeutic management of these tumors is often deriving from small case series, retrospective studies or even case reports. Evidences from prospective studies or controlled trials are limited and for this lack of clear and supported evidences, data from the medical literature on the topic are controversial, in terms of demographics, clinical presentation, diagnosis, prognosis and therapy. The correct recognition of the specific subtype and extension of the tumor through first line and second line radiology is essential for the surgeon, in order to effectively direct the therapeutic decisions.

Painful nails: A practical approach to the diagnosis and management of painful nail conditions

Because several nail disorders share similar clinical features, their diagnosis and management can be challenging to clinicians. The physical examination may disclose localized abnormalities or point to an underlying systemic disease, requiring additional workup. Furthermore, cosmetic distress and nail-related symptoms (e.g., tingling, stinging, numbness, and pain) are common factors that influence the patient's search for medical assistance. Nail pain (i.e., onychalgia) can accompany both localized and systemic pathology. Onychalgia can be acute or chronic according to the time of evolution; patients may describe it as intermittent or constant, and as a throbbing, burning, sharp, or shooting sensation denoting the nature of the pain. It may be exacerbated by colder temperatures, touch, and increased activity (e.g., manipulating objects, walking). We present four main groups of conditions that might cause nail pain: nail tumors, nail deformities, inflammatory or infectious diseases, and external or traumatic agents. Our article includes an overview of the clinical features, as well as diagnosis and management pearls for each entity. Physicians (dermatologists and nondermatologists) should be aware that abnormalities of the ungual and subungual space are not exclusive of dermatological disorders but may also be present in noncutaneous contexts.

Subungual exostosis of the finger in an 8-year-old girl

INTRODUCTION

Subungual exostosis (SE) is a relatively uncommon benign bone tumor that occurs in the distal phalanges of the toes or fingers.

CASE PRESENTATION

An 8-year-old girl presented for treatment of an acquired mass on the distal right index finger. The patient was preoperatively diagnosed with a benign bone tumor. Surgical resection of the distal right index finger mass was performed under general anesthesia, and histological examination of the resected tissue supported a diagnosis of SE of the right index finger. The surgical outcome was good, with no surgical site infection. Throughout 15 months of follow-up, the patient was asymptomatic with no recurrence.

CONCLUSION

Surgical resection of a mass on the distal right index finger resulted in absence of recurrence during 15 months of follow-up. SE is a benign and uncommon lesion that is infrequently encountered by physicians. This infrequent occurrence may result in delays in diagnosis and treatment. Complete excision of the lesion and careful separation from underlying nail bed structures results in total resolution of the lesion, while providing the lowest risk of recurrence.

Chondrogenic Bone Tumors: The Importance of Imaging Characteristics

BACKGROUND

 Chondrogenic tumors are the most frequent primary bone tumors. Malignant chondrogenic tumors represent about one quarter of malignant bone tumors. Benign chondrogenic bone tumors are frequent incidental findings at imaging. Radiological parameters may be helpful for identification, characterization, and differential diagnosis.

METHODS

 Systematic PubMed literature research. Identification and review of studies analyzing and describing imaging characteristics of chondrogenic bone tumors.

RESULTS AND CONCLUSIONS

 The 2020 World Health Organization (WHO) classification system differentiates between benign, intermediate (locally aggressive or rarely metastasizing), and malignant chondrogenic tumors. On imaging, typical findings of differentiated chondrogenic tumors are lobulated patterns with a high signal on T2-weighted magnetic resonance imaging (MRI) and ring- and arc-like calcifications on conventional radiography and computed tomography (CT). Depending on the entity, the prevalence of this chondrogenic pattern differs. While high grade tumors may be identified due to aggressive imaging patterns, the differentiation between benign and intermediate grade chondrogenic tumors is challenging, even in an interdisciplinary approach.

KEY POINTS

  · The WHO defines benign, intermediate, and malignant chondrogenic bone tumors. · Frequent benign tumors: osteochondroma and enchondroma; Frequent malignant tumor: conventional chondrosarcoma. · Differentiation between enchondroma versus low-grade chondrosarcoma is challenging for radiologists and pathologists. · Pain, deep scalloping, cortical destruction, bone expansion, soft tissue component: favor chondrosarcoma. · Potential malignant transformation of osteochondroma: progression after skeletal maturity, cartilage cap thickness (> 2 cm adult; > 3 cm child). · Potentially helpful advanced imaging methods: Dynamic MRI, texture analysis, FDG-PET/CT.

CITATION FORMAT

· Engel H, Herget GW, Füllgraf H et al. Chondrogenic Bone Tumors: The Importance of Imaging Characteristics. Fortschr Röntgenstr 2021; 193: 262 - 274.

A modified proximally based nail bed flap approach for benign subungual bone tumors in the distal phalanx

BACKGROUND

Complete tumor removal and damaged nail bed repair are critical factors that determine the success of subungual tumor excision. We examined a modified proximally based nail bed flap approach for excision of subungual bone tumors of the distal phalanx and present cases where this approach was used, along with postoperative functional and cosmetic outcomes.

METHODS

Twenty-four benign subungual bone tumors, identified from 23 patients (9 males and 14 females), were included in this study. All patients underwent tumor excision by the modified proximally based nail bed flap approach. Pain was assessed using a numeric rating scale, and cosmesis was self-assessed using a visual analog scale preoperatively and 1 year postoperatively. We measured sensation of the involved digit tip, relative to opposite-side sensation, using static and moving two-point discrimination and Semmes-Weinstein monofilament tests 1 year postoperatively. Lastly, we assessed postoperative nail deformities and tumor recurrence as potential surgical complications.

RESULTS

Mean pain severity and cosmesis were significantly improved 1 year postoperatively. There were no significant differences in the digit tip sensation between the involved and the opposite-side digits 1 year postoperatively. We observed one case of tumor recurrence and four cases of postoperative nail deformities.

CONCLUSIONS

The modified proximally based nail bed flap approach showed satisfactory functional and cosmetic outcomes. This approach enables a low rate of recurrence after removal of benign subungual bone tumors in the short term and cosmetically superior nail bed repair. Level of evidence: Therapeutic, IV.

A Novel Use of Umbilical Perinatal Graft in Subungual Exostosis Resection

Nail pathologies have a broad range of origin and may sometimes be complicated in presentation or clinical course, specifically when the pathology remains recalcitrant after treatment. In this case report we discuss a pathologic disorder that was initially misdiagnosed as a pyogenic granuloma surrounding an ingrown nail but was later found to be a benign neoplastic bone growth, Dupuytren exostosis, also known as a subungual exostosis. Operative treatment was deemed appropriate for the patient, and the exostosis was resected, leaving a soft-tissue void at the distal toe. The remaining void was filled with a perinatal graft, the use of which has been deemed effective anecdotally in both chronic and acute lower-extremity wounds but has not been widely discussed in the lower-extremity literature. This graft was placed to aid in wound healing over a potentially difficult wound bed. As amniotic, chorionic, and umbilical grafts become more prevalent in lower-extremity surgery, its antitumor effects should be further explored and published. This is the first case report, to our knowledge, of the successful use of a perinatal graft in the setting of a bone tumor, and it demonstrates that certain benign neoplasms can be treated with resection and placement of a perinatal graft while helping to prevent chronic wounds at surgical sites.

Subungual exostosis - treatment results with preservation of the nail bed

Subungual exostosis is a rare benign osteocartilaginous tumor, of unknown etiology, that affects the subungual part of the distal phalanx and predominantly affects adolescent females. The objective of this study is to evaluate the results of surgical treatment of subungual exostosis in pediatric patients by means of surgical excision and nail preservation. We present a retrospective study, including pediatric patients with subungual exostosis who underwent surgical treatment in a single institution, over a 6-year period, We describe the surgical technique used, the characteristics of the patients and lesions, and evaluate the results obtained in terms of function, satisfaction and complications. Thirteen patients were included in this study, seven female (54%) and six male (46%), median age 11 years old. The most common location was the hallux, in eight patients (73%). Patients had good functional results with a median American Orthopedic Foot & Ankle Society score of 100 [80; 100] and a median personal satisfaction score of 9. The median follow-up was 30 [3;68] months. In our patients, subungual excision with nail bed preservation, allows a good balance between the radical excision of the exostosis and the preservation of the natural protection granted by the native nail, yielding good functional results and patient satisfaction.

Subungual exostosis recurrence in a 16-year-old athletic male

Subungual exostosis is a painful, benign bony outgrowth projecting from the distal phalanx of the toes. The present case consists of a 16-year-old male that presented to the primary clinic with a single circumscribed painful lesion underneath the nail of the first phalanx of the left foot that recurred after surgical extraction.

Surgical Treatment on Subungual Osteochondromas in Paediatric Feet: A Case Series Study

Subungual osteochondroma (SO) is an infrequent and non-malignant bone tumour of the distal phalanx, especially prominent in paediatric populations. The aim of this research was to describe a case series of paediatric feet with SO which received surgical treatments. The secondary purpose was to compare these descriptive data by sex distribution. Methods: Twenty-three paediatric feet with SO confirmed by clinical or radiological features received surgical treatment. Socio-demographic (age, sex, height, weight and BMI) and clinical features (side, location, tumour or pain presence, and nail lift before surgery, as well as recurrence and adverse effects at one month after intervention) were reported. Results: Regarding clinical features before intervention, the most frequent locations of SO were the first toe (86.8%) and the right lower limb (56.5%). In addition, the presence of the tumour, pain and nail lift showed a prevalence of 91.3%, 69.5% and 47% of the study sample, respectively. Considering clinical features at one month after intervention, the most frequent adverse effect was the pain presence (69.5%). In addition, one case (4.4%) presented ulceration. Only one patient (4.4%) suffered from recurrence with a new tumour. There were not statistically significant differences by sex distribution (p > 0.05). Conclusions: This novel study showed that surgery treatment for SO in paediatric populations presented a very low recurrence degree with minor adverse effects and without differences by sex distribution. Thus, further randomized clinical trials should be carried out in order to determine the effectiveness of this intervention in this special population.

Onychalgia Causes and Mechanisms: The “GIFTED KID” and the “FOMITE”

This article gives an account of the commonest causes of nail pain. The acronyms GIFTED KID and FOMITE will help aid doctors in a busy clinical setting to remember the main causes of onychalgia, respectively, on the fingers and toes. It includes a brief overview of the clinical characteristics and focuses on the type of pain for each condition as well as the mechanisms that cause it.

Pediatric navicular dorsal osteochondroma: a rare case of navicular-cuneiform impingement

Osteochondroma is one of the most common benign bone tumors; however, as it rarely affects any bones in feet, it may easily escape detection without rigorous examination. We present an exceptionally rare case of tarsal navicular dorsal osteochondroma diagnosed in an 11-year-old female child affected by chronic foot pain. Radiographs, MRI, and computed tomography scan revealed bony excrescences extending outward from the navicular bone. After conservative treatment failed, the navicular dorsal exostosis was excised in open surgery with complete resolution of symptoms. Navicular-cuneiform impingement was diagnosed by instrumental and intraoperative techniques. Histological analysis confirmed the diagnosis of navicular dorsal osteochondroma. This case report illustrates the necessity of particularly rigorous evaluation of the substrates of pediatric chronic foot pain.

Osteoblastoma of the clavicle at the site of a previous fracture-first case report and review of the literature

Osteoblastoma is a rare, benign primary tumor of bone, accounting for < 1% of all bone tumors. We report the case of a 27-year-old female who developed pain and swelling five and a half years after a clavicular fracture and was subsequently found to have an osteoblastoma arising at the fracture site. This is the first reported case of an osteoblastoma developing after a fracture, although osteoid osteomas, which are histologically indistinguishable from osteoblastomas, have been reported at prior fracture sites. This report demonstrates that secondary neoplasms such as osteoblastomas should be considered in the differential diagnosis for pain at a healed fracture site recurring years after the initial trauma.

[Updates to the WHO classification of bone tumours]

The fourth edition of the WHO Classification of Soft Tissue and Bone Tumours, published in 2013, extends the approach to describe genetics and pathology of these tumours in the context of epidemiological, clinical and imaging data, which was adopted in the third edition. Added are a few new entities, reclassifications and renamings. The most important point, also of clinical relevance and with consequences for treatment, is the introduction of a stratification of bone tumours based on their biological behaviour into three groups (benign, intermediate, malignant) in analogy to soft tissue tumours.

Subungual Exostosis: High-Resolution Ultrasound Findings

Subungual exostosis is a rare solitary benign osteocartilaginous tumor that arises from the tuft of the distal phalanx beneath the nail. Because of its multiple clinical presentations, it is commonly underdiagnosed, resulting in delayed diagnosis and inadequate treatment. This report provides results from a 6-year retrospective study. All patients with a sonographic diagnosis of subungual exostosis confirmed surgically were selected. The data came from a series of 19 patient cases. Only 15.7% were clinically suspected. The median age was 21 years, and 63% were females. The sonographic findings were nail dystrophy, distal onycholysis, abnormal nail incurvation, subungual space enlargement, and the presence of hyperechogenic subungual image with acoustic shadowing that continued until the phalanx surface. Sonography provides an excellent diagnostic method for subungual exostosis, with findings that are pathognomonic.

Subungual exostosis in an 8-year-old child: clinical and dermoscopic description

We report the case of an 8-year-old child with subungual exostosis, whose diagnosis was suspected on the basis of dermoscopic findings and subsequently confirmed by X-ray and histopathology.

[Turrett's exostoses: about 35 casesk]

Nous rapportons à travers une étude rétrospective faite de 35 cas d’exostose sous unguéale de l’hallux dite exostose de Turrett's colligée entre 1995 et 2015 au service d’Orthopédie Traumatologie de l’Hôpital Militaire Principal d’Instruction de Tunis les résultats de la prise en charge de cette pathologie faite d’adultes jeunes d’âge moyen de 29 ans avec un sexe ratio de 1,7. Le délai moyen de consultation est de 18 mois. Ce retard de consultation est expliqué par une errance diagnostique en rapport avec une ressemblance du tableau clinique avec celui d’un ongle incarné. Le diagnostic est toujours confirmé par une radiographie de face et de profil de l’orteil intéressé. Le traitement a consisté en une exérèse radicale de l’exostose soit à travers une large fenêtre unguéale soit par un abord latéro-unguéal. L’examen anatomopathologique est systématique. Il a permis de confirmer la bénignité de l’affection dans tous les cas. La guérison a été de règle dans tous les cas avec une reprise de l’activité antérieure en 2 mois en moyenne. Aucune récidive n’a été notée.

Subungual Exostosis Systematic Review and Meta-Analysis

BACKGROUND

The coexistence of deformity of the nail bed and subungual exostosis (SE) is a frequent finding in podiatric practice in the fourth and fifth decades of life. However, it has been described by other specialists as being an uncommon osteocartilaginous tumor most prevalent during the second and third decades of life. This study attempts to determine the causes of this discrepancy.

METHODS

Two authors independently conducted a systematic bibliographic review in multiple databases, podiatry sources and others, and key words were chosen to achieve a broad search strategy. Studies reporting on epidemiology and treatment of SE lesions in lower extremities in ten or more patients were selected. Initially, 197 articles were identified through database screening, with 23 meeting all inclusion and exclusion criteria. Seven articles with the ages of all of the patients were included in the analysis of age data. A comparison was then made between the diagnostic criteria for the selected 23 articles.

RESULTS

Model results reveal that, although there are some significant differences between individual studies, the main factor tested (patient's age) was clearly significant ( F_1,5.2 = 78.12, P < .001), showing that studies coming from the podiatry speciality were conducted on individuals with a mean age of 37 years higher than in studies from other specialties. Clinical and radiologic characteristics and treatment described in the podiatry literature also contrast with those in other specialties.

CONCLUSIONS

The SE described by podiatrists, in accordance with the parameters of true exostosis, is different from Dupuytren's SE and should be considered as a different pathologic entity. The authors are working on its histologic identification.

Subungual Exostosis in a Young Soccer Player

BACKGROUND:

Subungual exostosis is a relatively uncommon, benign osteocartilaginous tumor of the distal phalanx of the toes or fingers in young adults, considered as a rare variant of osteochondroma. Differential diagnoses include subungual verruca (viral wart), pyogenic granuloma, osteochondroma, amelanotic subungual melanoma and glomus tumour. Misdiagnosis and total onychodystrophy frequently occur as a result of late treatment or inadequate treatment strategy. Dermoscopy could be a useful technique, involved in the diagnostic process, although X-ray examination and histopathology are mandatory for the diagnosis.

CASE REPORT:

We report a rare case of subungual exostosis of the great toe associated with repeated trauma of the nail bed. The lack of radiographic and histopathological examination could lead to misdiagnosis and inadequate treatment. Although completely benign, subungual exostosis should be considered in differential diagnosis of nail bed tumors in young adults, in order to avoid associated complications and unneeded aggressive surgical interventions.

CONCLUSION:

Complete excision of the lesion and delicate separation from the underlying nail bed structures results in total resolve of the problem, by providing the lowest risk of recurrences.

Osteochondroma: Review of 431 patients from one medical institution in South China

BACKGROUND

The geographic distribution of osteochondroma (OC) varies greatly around the world. There has been no recent report on OC in a large Chinese population. The aim of this study was to characterize OC by an epidemiological analysis of the clinical data from one medical institution in South China.

METHODS

We searched medical electronic records from January 2001 to January 2016 in one large hospital in South China to identify patients with a definite diagnosis of OC. Their epidemiological data were collected and analyzed statistically, including gender, tumor site, age at first diagnosis and symptoms, local recurrence and malignant transformation. Differences between genders and between solitary osteochondroma (SO) and multiple osteochondroma (MO) were particularly analyzed.

RESULTS

A total of 431 OC patients (291 males and 140 females; 329 SOs and 102 MOs) were identified. The gender ratio was 2.08 with a male predominance. OCs were mostly located around the knee (250 cases). 280 patients were in their 0s to 20s upon first diagnosis. The average age at the time of first diagnosis was 20.63 years for all, 18.47 years for males and 25.11 years for females (P=0.000). OC recurred locally in 35 patients (15 SOs and 20 MOs), with a significant difference between SO/MO (P=0.000) but not between genders (P=0.100). The average interval from the primary surgery to local or malignant recurrence was 37.41 months. Malignant transformation was found in 5 patients (4 males and 1 female), showing no gender difference (P=0.549).

CONCLUSIONS

OC may have a male predominance in Chinese population. It mostly occurred at 0-20 years of age and around the knee. Upon the first diagnosis of OC, the males tended to be younger than the females, and so did the MO patients than the SO ones. In addition, MO had a higher incidence of local recurrence. Intervals from primary surgery to local recurrence or malignant transformation in MO patients were longer than in SO patients.

Bone tumors of the pediatric foot: imaging appearances

Tumors of the foot are rare in children. This review illustrates radiographic, CT and MR imaging findings of foot bone tumors in children based on all cases presented in a tertiary pediatric hospital during the 15-year period of 1999-2014. This search revealed 155 tumors of the foot, 72 of the bones and 83 of the soft tissues. Osteochondroma, bone cyst and fibrous dysplasia were the most frequent benign bone lesions. Ewing sarcoma was the most common malignant osseous tumor. Some tumors showed higher prevalence in certain age ranges and others showed predilection for specific bones. Radiographs are useful for diagnosis in the majority of cases but CT and MR imaging provide additional valuable information in select cases for diagnosis and determining extent of the lesions. Radiologists should be aware of some typical imaging findings in bone tumors of the foot in order to establish diagnosis and facilitate patient management.

Assessment of the Pediatric Foot Mass

Masses in the pediatric foot are relatively uncommon and can present a diagnostic challenge. The literature lacks a comprehensive overview of these types of lesions. Most are benign soft-tissue lesions that can be diagnosed on the basis of history and physical examination. However, some rare malignant neoplasms can mimic benign masses. It is imperative to recognize these lesions because the consequences of a delayed or missed diagnosis can be substantial. A thorough history and physical examination of all pediatric patients with foot lesions are crucial to ensure that any lesion not readily identified as benign is appropriately managed.

Dystrophy of the Great Toenail by Subungual Exostosis and Hyperostosis: Three Case Reports with Different Clinical Presentations

Subungual exostoses and hyperostoses of the great toenail are a differential diagnosis of nail tumors. We present 3 cases of subungual exostosis/hyperostosis with secondary nail dystrophy: a 36- and a 37-year-old woman as well as an 8-year-old boy. Two of the 3 patients suffered from pain. The 2 female patients presented with the classic dorsolateral firm protrusion, while the child presented with bilateral nail dystrophy with lateral wall hypertrophy. In this later case, a bony ridge was identified, which is an unusual subungual, nonprotruding type of exostosis. The hypertrophic lateral walls were removed by the Vandenbos technique. In the 2 former cases, complete excision of the bony lesions was performed with a proximal block. Healing by second intention was uneventful.

Nail Disease for the Primary Care Provider

Nail disorders are a common presenting complaint for both the primary care physician and the dermatologist. Nail diagnoses are broad in scope and include infectious, inflammatory, and neoplastic conditions. Onychomycosis is an especially common nail condition, and treatment should always be preceded by appropriate fungal studies for confirmation of diagnosis. Inflammatory conditions of the nail unit can mimic onychomycosis, and a dermatologist can assist with diagnosis and treatment recommendations. Likewise, subungual tumors often require biopsy, and should be evaluated by a dermatologist who is experienced in nail evaluation and treatment.