AN UNEXPECTED

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

REVIEW OF SYSTEMS

HEENT: Denies vision

Respiratory: Denies
problems. Denies hearing
Cardiac: Denies chest pain, shortness of breath,
problems. No dysphagia, Endocrinology: Pt denies
chest pain on exertion, shortness of breath on
odynophagia. No lumps in diabetes, no thyroid issues
palpitations. exertion, cough, hemoptysis,
neck. No epistaxis. No
wheeze.
hemoptysis.

GI: No nausea, no vomiting,

no diarrhea, no melena, no Neuro: Denies neuropathic
Muscle Skeletal: Denies Skin: Denies rashes, jaundice
hematochezia, no pain, seizures, ataxia or
swelling or pain. or lesions.
constipation. BMs regular. vertigo symptoms.
Denies abdominal pain.
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


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
PHYSICAL
EXAMINATI
ON MUSCULOSKELETAL EXAM:
Muscle strength normal for
plantarflexion, dorsiflexion,
inversion and eversion b/l;
ROM within normal ranges 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
DERMATOLOGICAL EXAM:
LEFT hallux nail plate semi-
attached , dystrophic
with onycholysis; firm
protruding mass from the
distal aspect of the left hallux
CLINICAL PRESENTATION

Dystrophic nail plate detached

from nail bed

Firm mass protruding from nail bed

IMAGING
X-ray demonstrates a
POSSIBLE subungual
exostosis
 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
SURGERY
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
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.
 • 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
PATHOLOGY • In part B histologic examination demonstrates a
polypoid/protuberant fragment of trabecular bone
REPORT
• Conclusion: Represents a
supernumerary digit, particularly if
it was present from birth.
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
 • 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
CONCLUSION the patient had since birth
THANK YOU
FOR YOUR
ATTENTION