Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

HPI: A 10 y/o African American male presents to clinic with a complaint of right foot pain for approximately one month. The patient states that his pain is predominantly associated around a large callus formation along and between the 3rd and 4th metatarsal heads. The patient states that, in addition to the pain, the callus has recently formed over the last month or so. The patient relates that he may have stepped on something around this location, but doesn�t specifically remember. The patient relates that the pain is constant with weight bearing, and his mother states that he has begun to walk on the outside of his foot, and that he has stopped participating in sports activities because of the pain. The patient denies any recent history of coughs or colds, and denies recent history of fevers, chills, or any other constitutional symptoms.

PMH: denies any previous medical history

FMH: noncontributory with no family member having history of similar lesions

PSH: denies previous surgical history

MEDs: takes a multivitamin daily

ALL: NKDA

SOCIAL: Lives with mother, until recently was active in sports, but has since stopped participating due to the pain in his right foot

PE: The patient is Afebrile with vital signs stable Pedal pulses palpable at DP, and PT on the right foot, with CFT <3 seconds. Positive digital hair growth noted.  Muscle strength is +5/5 in all muscle groups tested, range of motion at ankle and subtalar joint is within normal limits without crepitation or pain elicited with passive range of motion.  There is a visibly appreciable prominence noted along the plantar aspect of the right foot located just proximal to the 3rd metatarsal head region with mild medial extension.  There is significant hyperkeratotic tissue formation noted around the prominence, which is elevated from the surrounding skin approximately 5 mm (fig. 1).  Upon palpation of the area, there is an appreciable mass beneath the verruca-like hyperkeratotic lesion that appears to be a nonfluctuant, nonpulsatile solid soft tissue mass that is fixed in the skin, yet feels loosely adherent to the underlying subcutaneous tissues.  The mass is painful to palpation, and the pain is graded 8/10 at this time.  Protective sensation is grossly intact via 5.07 semmes-weinstein monofilament test, and the patients vibratory sense is intact via tuning fork.  Deep tendon reflexes are graded +2/4 bilaterally at both the Achilles and patellar tendons.

Fig. 1: The verruca-like superficial hyperkeratotic lesion which is overlying the soft tissue mass is visible.

Radiographs: X-rays obtained of the right foot demonstrate a skeletally immature patient with open physis noted.  There are no fractures or dislocations noted, no calcifications or periosteal changes noted in the area of the palpable soft tissue mass of the right foot.

Treatment Plan: Considering the unusual nature of the presentation and the age of the patient, the hyperkeratotic tissue was debrided away from the superficial lesion to evaluate for the presence of any pin-point bleeding and to all for better visualization and evaluation of any underlying soft tissue mass.  Prior to this, the patient was administered 10cc of 1% lidocaine plain via ankle block to provide anesthesia for the procedure.

Upon removal of the superficial hyperkeratosis, a small sinus tract was observed, which was further investigated, and upon widening of the sinus, the plantar surface of a mildly compressible soft tissue mass was observed (fig.2).

Fig. 2: Following initial débridement, the sinus tract is visible, and has been enlarged to allow for better visualization of the underlying tissue mass.

At this time a needle aspiration was performed which yielded no fluid, however a small amount of white, viscous material was noted to be expressed from the previous site of the aspiration with compression of the soft tissue mass.  A culture of this exudate was obtained and sent for C&S as well as gram staining. Utilizing careful dissection the mass was removed in total from the right foot through the established sinus and was passed from the field (fig. 3) to be sent for gross pathological evaluation.

Fig. 3: The soft tissue mass measuring approximately 1cm2 was removed in total and sent for gross pathological evaluation.  A deep wound culture was obtained as well, and sent for culture and sensitivity

At this time the wound was flushed with normal saline, and hemostasis was obtained with compression.  The wound edges were reapproximated with one 3-0 prolene suture utilizing horizontal mattress suture technique (fig 4).

Fig. 4: The wound was closed with 3-0 prolene utilizing horizontal mattress suture technique

The wound was dressed with adaptic and covered with a dry sterile dressing consisting of 4x4, cling, and coban wrap.  Following the procedure, the patient was placed in a darco-wedge shoe, and given instructions to not to ambulate or bear weight to the right foot without the aid of the offloading shoe.  The patient was given instructions to return to clinic in one week, with removal of sutures anticipated at two weeks.

Considering the clinical exam presented, and the physical and imaging findings, how would you proceed in the management of this patient?  Follow this link or click on the image below, to participate in the eTalk thread on this topic. The Conclusion of this case will be posted in an upcoming Residency Insight.

I look forward to reading your responses for this case presentation. In part 2, I will give you the pathology report and tell you all about this interesting condition.  With your continued participation, we can greatly increase our collective knowledge and therefore make us all better physicians and surgeons.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.

Get a steady stream of all the NEW PRESENT Podiatry eLearning by becoming our Facebook Fan. Effective eLearning and a Colleague Network await you.

Grand Sponsor
Major Sponsors