Subungual Exostosis
True subungual exostoses arise from the tuft of the distal phalanx. They are composed of mature bone with a fibrocartilaginous cap. Lee et al (2007) noted that half of their subungual lesions were actually osteochondromas arising from the proximal part of the distal phalanx and covered with hyaline cartilage organised as in a growth plate. True exostoses are commonest in young adults with a female predominance. They mainly occur in the great toe, although they also occur in the lesser toes and fingers.
They present with a complaint of pain in the toe, sometimes localised to the nail fold. Sometimes the swelling itself may cause pressure on the shoe. Some have a history of trauma or previous nailbed surgery (which may have been for an “ingrowing toenail’ that was, in fact, the exostosis).
Examination shows a firm swelling under the nail, usually in the medial nail fold. It is usually covered with epidermis, but may be raw or granulating.
The main differential diagnosis is ingrowing toenail, with a nailbed tumour such as melanoma, squamous carcinoma or glomus tumour as a much rarer possibility.
The lesion normally continues to grow so is best removed when diagnosed. This can be done under digital block anaesthesia as a day case. Sometimes the nail fold can be elevated and preserved, but usually it cannot be separated from the lesion and must be sacrificed. Even with careful excision of the whole lesion, the recurrence rate averages about 10%. A few patients require removal of so much nail bed that there is significant post-operative nail deformity, so that plastic nail bed reconstruction may be consdered (Suga 2005).
If you feel you may have a painful subungual exostosis, please see Dr. Silvers at Advanced Foot and Ankle Center for treatment.
References
- De Berker DA, Langtry J. (1999). Treatment of subungual exostoses by elective day case surgery. Br J Dermatol 140(5): 915-8
- Dalle S e al. Squamous cell carcinoma of the nail apparatus: clinicopathological study of 35 cases. Br J Dermatol. 2007;156(5):871-4
- Gray RJ et al. Diagnosis and treatment of malignant melanoma of the foot. Foot Ankle Int 2006; 27:696-705
- Lee SK et al. Two distinctive subungual pathologies. Subungual exostosis and subungual osteochondroma. Foot Ankle Int 2007; 28:595-601
- Suga H et al. Subungual exostosis: a review of 16 cases focusing on postoperative deformity of the nail. Ann Plast Surg. 2005;55(3):272-5
Madura Foot
What is Madura Foot?
Madura foot is terrible, destructive infection of the skin and deeper tissues. Oftentimes, the infection can reach deeper tissues such as muscle and bone.
It is noted that different species of fungus or bacteria can cause madura foot.
In the United States, Madura foot is most often caused by an organism called Pseudallescheria boydii. Now that’s a mouth full!
Although Madura foot may occur throughout the world, it is most common in dry, tropical, and rural settings. Therefore, this may not be seen very often in Texas, especially North Texas.
Madura foot is usually painless and has 3 characteristic features:
1. Formation of a nodule or lump at the site where the organism is first received, such as a penetrating injury like a puncture wound.
2. There is noted pus and tunneling into the skin at the site of the wound.
3. There is noted “grains” or “granules” within the drainage.
The infection can cause severe swelling and enlargement of the affected leg or foot. The infection can become painful if bone is involved.
Treatment often involves antibiotics and antifungal medications, but amputation is often the end result.
If you feel you may have Madura foot, please come see Dr. Silvers and he can refer to the proper Infectious Disease specialist.
Clawtoes
Definition
A claw toe is a toe that is contracted at the PIP and DIP joints (middle and end joints in the toe), and can lead to severe pressure and pain. Ligaments and tendons that have tightened cause the toe’s joints to curl downwards. Claw toes may occur in any toe, except the big toe. There is often discomfort at the top part of the toe that is rubbing against the shoe and at the end of the toe that is pressed against the bottom of the shoe.
Claw toes are classified based on the mobility of the toe joints. There are two types – flexible and rigid. In a flexible claw toe, the joint has the ability to move. This type of claw toe can be straightened manually.
A rigid claw toe does not have that same ability to move. Movement is very limited and can be extremely painful. This sometimes causes foot movement to become restricted leading to extra stress at the ball-of-the-foot, and possibly causing pain and the development of corns and calluses.
Cause
Claw toes result from a muscle imbalance which causes the ligaments and tendons to become unnaturally tight. This results in the joints curling downwards. Arthritis can also lead to many different forefoot deformities, including claw toes.
Treatment and Prevention
Changing the type of footwear worn is a very important step in the treatment of claw toes. When choosing a shoe, make sure the toe box (toe area) is high and broad, and can accommodate the claw toes. A shoe with a high, broad toe box will provide enough room in the forefoot area so that there is less friction against the toes.
Other conservative treatments include using forefoot products designed to relieve claw toes, such as toe crests and hammer toe splints. These devices will help hold down the claw toe and provide relief to the forefoot. Gel toe shields and gel toe caps are also recommended to eliminate friction between the shoe and the toe, while providing comfort and lubrication.
Hammertoe Crest Pad
Gel Toe Cap
Budin splint / Toe Straightener
If you feel you may have clawtoes, please come see Dr. Silvers for treatment.
The address to our facility is as follows:
McKinney Office Location
4501 Medical Center Drive: Suite 300
McKinney, TX 75069
To schedule an apppointment, please call : 972-542-2155
Prosper Office Location
140 N. Preston Road: Suite 30
Prosper, TX 75078
To schedule an appointment, please call: 972-542-2155
Crazy Shoes: Are These For Real?
I thought you guys might get a laugh when looking at these absurd shoes.
Enjoy! Have a great day!
P.S. – These are not recommended to wear.
New Foot Prosthetics
I found this link on WebMD showing some new innovations in prosthetic limbs.
Click on the link to watch this video: Artifical Foot Prosthetic
Subungual Hematoma
Have you ever been cooking in the kitchen and dropped a can of vegetables on your toenail ? Have you ever ran for a long time and developed blood under a toenail. I am guessing at some point you have had blood under the nail plate whether due to direct trauma or repetitive microtrauma. The scientific name for blood under the nail plate is subungual hematoma.
Subungual hemoatomas develop because the arteries in the nailbed (the tissue between the nail plate and the bone) get damaged. There is a potential dead space or vacant space that can form between the nail plate and the nail bed, which can fill with blood.
The pressure from the blood under the nail can cause severe pain.
Most patients present with with a swollen toe and complaints of throbbing pain following injury. The 2 most common mechanisms are repetitive microtrauma from sports such as running or tennis or direct trauma from a crush-type injury.
When looking at the nail plate, if the blood takes up more than 25% of the nail plate, then a fracture of the bone underneath usually occurs.
Treatment involves draining of the blood to relieve the pressure. Hematomas involving less than 25% of the nail plate are usually drained by poking a hole through the nail plate with a heated paperclip, a needle, or a hand-held cautery tool. Once the nail plate is penetrated, the blood under the nail is expressed using slight pressure. The area should then be cleansed a dressed with a sterile dressing.
When the blood collection involves more than 25% of the nail plate, there is increased risk of nail bed laceration. Therefore, complete removal of the nail is required in order to properly evaluate the entire nailbed.
Decompression of a subungual hematoma is quick, easy and painless. Patients feel immediate relief and generally have no complications following prompt drainage. Usually the nail will come off on its own in approximately 6 weeks after the trauma, and a new nail is regrown by 6-9 months without being disfigured.
