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A Soccer Player With a Sore Toe

Recognizing Subungual Osteochondromas

Gunesh P. Rajan, MD; René Zellweger, MD; Otmar Trentz, MD


In Brief: In contrast to usual osteochondromas, subungual osteochondromas may arise following trauma rather than from aberrations in bone development. The rarity of subungual osteochondromas frequently leads to misdiagnosis and undertreatment, especially as a sports injury. When patients have nail-bed bruising, x-rays can rule out or confirm bone involvement, as in our case of a 20-year-old soccer player who had increasing pain in his left great toe. Treatment consists of radical, anatomic resection of symptomatic osteochondromas with periosteal realignment to prevent recurrence. Functional outcome after resection is excellent.

A 20-year-old premier league professional soccer player with increasing pain in his left great toe came to our emergency department. The player's toe problems had started 3 months earlier during a soccer game in which the patient made a forceful volley kick with his left foot. Immediately after the kick, he felt a strong stinging pain in his left great toe and, on self-inspection, found what he described as subungual bruising with hematoma formation. He assumed that it would heal spontaneously as had other previous minor foot injuries. The pain persisted and, 2 weeks before he presented to our emergency department, the patient noted subungual pus formation. He consulted his family doctor who prescribed antibiotics and local anti-inflammatory creams. Due to persistent, immobilizing pain of the toe, he came to our emergency department.

On physical examination, the left great toe showed a normal position with no signs of subluxation, malalignment, or perifocal inflammation. The proximal nail bed was filled with pus and manifested pain upon pressure on the nail. Blood film and chemistry analyses did not show signs of bacterial infection, and pus cultures were negative.

To rule out bone involvement, radiographic examination of the toe was performed. Radiographs revealed a spike-shaped bone sclerosis emerging from the distal third of the dorsal terminal phalanx of the left great toe. No periosteal reaction, osteolysis, or calcifications were evident (figure 1).

[Figure 1]

At surgery, the lesion in the dorsomedial cortex of the distal phalanx was identified as a finger-cup-shaped mass, 4 mm long, with a bony neck and a cartilage tip, suggesting an osteochondroma. An en bloc resection was performed, and histologic examination confirmed the diagnosis of a pleomorphic osteochondroma.

One month after surgery, the patient was pain free and had a normal range of motion in the left great toe, so he resumed soccer training. Radiographic follow-up was unremarkable, with no evidence of recurrence (figure 2).

[Figure 2]


Literature reports (1-5) associate bone trauma with repeated exertional microtrauma, especially in athletes. Several reports (3-5) have shown occurrences of exostosis in toes, with most of them demonstrating the classic histologic pattern of a hyaline cartilage cap with cancellous bone body. In some reports (4,6), pleomorphic patterns are described without malignant transformation. Causes of such subungual exostosis are controversial, and some pathologists regard the disorder as a developmental malformation.

Our patient probably experienced a bone bruise of the toe 3 months earlier. Constant movement and pressure may have led to reactive osteochondroma formation that caused pressure necrosis of the proximal nail bed with sterile pus formation. In our patient, other x-rays taken prior to the trauma did not reveal any exostosis in the great left toe. Until the kick trauma, our patient had never experienced comparable toe problems. As a result of these findings and our comparison of the patient's history and pre- and posttraumatic x-rays, we concluded that the toe trauma led to the reactive osteochondral formation.

Another aspect favoring a traumatic cause in our patient is the histologic/pleomorphic pattern of the resected probe. Resection is strictly anatomic with minimal periosteal traumatization, thus reducing the possibility of recurrence. To prevent uncontrolled callus formation, the most common complication, some authors (3,4,7) recommend adapting the periosteal sheaths as an alignment and barrier. Postoperative local glucocorticosteroid injections haven't shown any benefit in reducing recurrence (2,4,5). In general, the surgical risk for the management of osteochondroma is low and comparable to the risk of other related elective procedures (7); however, osteochondromas need to be resected only if symptoms arise or if radiographic features indicate a malignancy or abnormal increase in size (3,5).


  1. Bandiera S, Bacchini P, Bertoni F: Bizarre parosteal osteochondromatous proliferation of bone. Skeletal Radiol 1998;27(3):154-156
  2. Day FN, Ruggieri C, Britton C: Recurrent osteochondroma. J Foot Ankle Surg 1998;37(2):162-164
  3. de Palma L, Gigante A, Specchia N: Subungual exostosis of the foot. Foot Ankle Int 1996;17(12):758-763
  4. Fikry T, Dkhissi M, Harfaoui A, et al: Subungual exostoses: a retrospective study of a series of 28 cases [in French]. Acta Orthop Belg 1998;64(1):35-40
  5. Greger G, Catanzariti AR: Osteochondroma: review of the literature and case report. J Foot Surg 1992;31(3):298-300
  6. Porter DE, Simpson AH: The neoplastic pathogenesis of solitary and multiple osteochondromas. J Pathol 1999;188(2):119-125
  7. Wirganowicz PZ, Watts HG: Surgical risk for elective excision of benign exostoses. J Pediatr Orthop 1997;17(4):455-459

Dr Rajan is a trauma surgery resident, Dr Zellweger is a staff trauma surgeon, and Dr Trentz is head of the Division of Traumatology, Department of Surgery at University Hospital in Zurich, Switzerland. Address correspondence to Gunesh P. Rajan, MD, ENT Surgery Dept, University Hospital, CH-8091 Zurich, Switzerland; e-mail to [email protected].