nypod conference

1. AN UNEXPECTED
PRESENTATION OF A
SUPERNUMERARY DIGIT
PRESENTED BY: AKASH J SHAH PGY-2
MAIMONIDES MIDWOOD COMMUNITY HOSPITAL

2. HISTORY
• 30 y/o F presents with a painful left hallux. Patient states
that she banged and broke her left foot great toe several
years ago and was told that she had a small fragment of
bone under the toe nail
• Patient states that over the course of her healing, the left
foot great toe nail thickened and lift off her toe
• Numerous visits to the ED, with no resolution of symptoms

3. REVIEW OF SYSTEMS
Cardiac: Denies chest pain,
chest pain on exertion,
palpitations.
HEENT: Denies vision
problems. Denies hearing
problems. No dysphagia,
odynophagia. No lumps in
neck. No epistaxis. No
hemoptysis.
Endocrinology: Pt denies
diabetes, no thyroid issues
Respiratory: Denies
shortness of breath,
shortness of breath on
exertion, cough, hemoptysis,
wheeze.
GI: No nausea, no vomiting,
no diarrhea, no melena, no
hematochezia, no
constipation. BMs regular.
Denies abdominal pain.
Muscle Skeletal: Denies
swelling or pain.
Neuro: Denies neuropathic
pain, seizures, ataxia or
vertigo symptoms.
Skin: Denies rashes, jaundice
or lesions.

4. HISTORY
PMH : unremarkable
PSHx: none
Social Hx: non-smoker; no recreational drugs; denies use of alcohol
Allergies : no known drug or food allergies
Medications: clotrimazole 1% topical solution

5. PHYSICAL
EXAMINATION
VASCULAR EXAM: DP/PT
pulses 2/4 b/l; CRT < 3 sec b/l;
STG warm to cool b/l; pedal
hair present b/l
NEUROLOGICAL EXAM:
Sharp/dull sensation intact
b/l; proprioception sensation
intact b/l; vibratory sensation
intact b/l; protective sensation
to 5.07 monofilament intact
b/l; negative Babinski
response b/l; deep tendon
reflexes intact and
symmetrical b/l
MUSCULOSKELETAL EXAM:
Muscle strength normal for
plantarflexion, dorsiflexion,
inversion and eversion b/l;
ROM within normal ranges b/l
DERMATOLOGICAL EXAM:
LEFT hallux nail plate semi-
attached , dystrophic
with onycholysis; firm
protruding mass from the
distal aspect of the left hallux

6. CLINICAL PRESENTATION
Dystrophic nail plate detached
from nail bed
Firm mass protruding from nail bed

7. IMAGING
X-ray demonstrates a
POSSIBLE subungual
exostosis

8. SURGERY
Total hallux nail avulsion performed in
the OR
Through the use of c-arm imaging, the
mass was identified and removed
utilizing a #15 blade and sagittal saw
The surgical site was reapproximated
utilizing 3-0 monocryl and dressed with
bacitracin, 4x4 gauze and kling as well as
a light ace bandage for compression

9. PATHOLOGY
• The mass removed had the appearance of a digit
with complete nail bed , representing a possible
supernumerary digit.
• The specimen was sent to pathology for
further evaluation.

10. PATHOLOGY
REPORT
• A) Nail, left foot, big toe revealing keratinizing squamous
epithelium and nail plate with focal bacterial cocci
• B) bone, left foot, big toe excision:
• Trabecular bone with overlying fibroconnective tissue and
skin with reactive changes
• Comment: in part A, pas-d stain is negative for fungal
organisms
• In part B histologic examination demonstrates a
polypoid/protuberant fragment of trabecular bone
• Conclusion: Represents a
supernumerary digit, particularly if
it was present from birth.

11. WHAT IS A
SUPERNUMERARY
DIGIT?
• Greek poly (many)
and dactylos (finger)
• A supernumerary digit, or
polydactyly, is a congenital anomaly
affecting the upper or lower
extremities and is typically identified
immediately after birth. Polydactyly is
the most common congenital
anomaly of the hand and foot, where
affected individuals typically exhibit
excessive fingers or toes, exceeding
the usual count of 5

12. CONCLUSION
• Definitive diagnosis sometimes cannot be given
without final pathology report. In this case, we
suspected that it was a subungual exostosis, but
it turned out to be a supernumerary digit that
the patient had since birth

13. THANK YOU FOR
YOUR ATTENTION