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Subungual exostosis - Differential Dx?

Discussion in 'General Issues and Discussion Forum' started by pieds, Jun 17, 2010.

  1. pieds

    pieds Welcome New Poster

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    An 80 yr patient presented, complaining of a 'sore big left toenail'. Assessment of the toe revealed no external signs of trauma, infection or involution. Nail sulci were completely clear of debris and nail edge was visible. Direct compression of the toenail ellicted pain, which immediately made me consider subungual exostosis. I couldn't acertain whether there was any additional blanching of his nailbed, as both L and R hallux nailplates were pale in colour.

    I am keen to get possible differential diagnoses in light of his other symptoms and med Hx: temperature of his feet was hot distally, but cooler proximally, which was unusual. Skin slightly anhydrotic. Erythema extended unilaterally into the distal 1/3 of the left limb. The 'erythema' took on the appearance of tiny pinpoint capillaries sub-epidermally, as opposed to irritation on the surface of the skin. The erythema was not symptomatic. The patient is also living with asbestosis (on oxygen permanently), emphysema and leukaemia. Now he has a sore toe to add to his problems!

    I have read that x-rays may not be the best way of diagnosing a sub-ung exostosis, particularly if it has a cartilagenous cap. What is the best way to conclusively diagnose this condition? Could it be something more sinister in light of his medical history?

    Interested in your advice and suggestions!
  2. Admin2

    Admin2 Administrator Staff Member

  3. Johnpod

    Johnpod Active Member

    Bonjour pieds,

    A genuine exostosis will 'rock' on the bony protrusion. Use both thumbnails on the lateral nailplate and depress each side in turn. If the nail will not depress there is most likely a subungual exostosis.

    Given the quoted history there is more likely to be a smelly, wet, sterile ulceration beneath the nail - probably best left alone if all else settled.
  4. pieds

    pieds Welcome New Poster

    Oooh, now I wasn't expecting that! Thank you for that advice!! I will give the 'nail rock' technique a go too.
  5. G Flanagan

    G Flanagan Active Member

    x-ray, lateral view (and DP for good measure) you should see it if one is there.

    I don't know anyone that wouldnt get a plain film for a suspected subungual exostosis. Sometimes the books have a very good theory base but practically you need to use common sense.

    DDx, subungual heloma, periungual fibroma, ulceration erm.......
  6. pieds

    pieds Welcome New Poster

    Much appreciated, G. Thanks a lot for your useful advice!
  7. Thurman

    Thurman Welcome New Poster

    an isolated lateral view would aid visualisation without superimposition.
  8. drsarbes

    drsarbes Well-Known Member

    80 y/o with COPD of various etiology, distal hyperemia, sensitivity at the distal digits, punctate subQ hemorrhagic lesions...................

    First: subungual exostosis would - of course - be demonstrated on plain xray films.
    Second: perhaps his symptoms are secondary to his general medical condition.


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