Subungual exostosis and subungual osteochondromas: a description of 25 cases

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.

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 of the Hand: A Case Report in a 5-Year-Old Boy and Literature Review

Subungual exostosis is a relatively uncommon benign tumor that occurs at the distal end of the distal phalanx of the toes and rarely the hands. We present in this article a review of the currently published English literature and provide a case report of a 5 year old male with subungual exostosis of the thumb.

A 5 year old male presented with a slow growing mass of the distal dorsal aspect of the left thumb. Radiographs showed dorsal calcifications on the thumb. Surgical removal of the mass and histopathological analysis was performed supporting a diagnosis of subungual exostosis. Post-operatively, the patient had complete excision of the mass, normal nail morphology, no reoccurrence, and no post-surgical complications.

Subungual exostosis remains a rare entity especially in the upper extremity. Its cause is not fully understood, nor is there an agreed upon method of treatment. However, with careful dissection during surgical removal good outcomes can be obtained. To our knowledge, this is the largest literature review on subungual exostosis and our case report is an uncommon presentation in the youngest reported male patient. It is our hope that this literature review and case report lend to increased awareness of subungual exostosis and how to diagnose and treat this lesion.

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.].

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.

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.

Grafting and Other Reconstructive Options for Nail Deformities: Indications, Techniques, and Outcomes

This article reviews the nomenclature, anatomic components, and physiologic growth involving the perionychium. Fingertip and nailbed injuries are commonly encountered problems in hand surgery. This article focuses primarily on dealing with chronic nailbed deformities following traumatic injury such as nonadherence, split nails, avulsion loss, and hook nails. Nail deformities secondary to pincer nail, mass effect, and pigmented lesions are reviewed as well. The underlying pathology and treatment options are examined for each deformity. The senior author highlights technical pearls and surgical planning for his preferred methods of reconstruction.

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.

Subungual Tumors: An Algorithmic Approach

The presentation of benign and malignant subungual tumors often follows a final common pathway of nonspecific nail deformity; as such, delays in diagnosis are common. Therefore, it is imperative to have a high degree of suspicion for malignant lesions and an organized approach to subungual tumors. To that end, we present a diagnostic algorithm encompassing the most common benign and malignant subungual tumors, along with a summary of the presentation, imaging, and treatment of these lesions.