Case Study: Treating A Patient With Painful And Aggressive Periungual Fibromas
Radiologic examination revealed an increase in soft tissue density and volume at the distal aspect of the third, fourth and fifth digits, and erosive changes in the distal phalanges on the left foot. We obtained a magnetic resonance image (MRI) to identify the amount of soft tissue involvement. It revealed hyperintense lesions relative to muscle along the nail beds of multiple digits on the left foot compatible with the clinical history of periungual fibromas.
Prior to surgery, conservative treatment options included custom molded shoes or orthopedic accommodative shoes, but the patient revealed that these were not satisfactory options for her. The patient exhausted all conservative treatment prior to surgical planning.
Pertinent Insights On Treatment And Post-Op Care
The patient underwent surgical removal of the periungual fibromas on her left foot. We excised the soft tissue masses on the left third, fourth and fifth digits, all of which measured 2 cm. During the excision of soft tissue, we performed an amputation of the distal portion of the distal phalanx to ensure proper wound closure. Pathologic findings for the samples submitted for the left third, fourth and fifth digits revealed skin with papillomatosis and fragment of benign bone, consistent with periungual fibromas.
The patient received postoperative instructions to bear weight as tolerated on the left upper extremity with a surgical shoe and single point cane assist.
Postoperative radiographs revealed partial amputation of the distal phalanges and postoperative changes consistent with removal of the tumors on the left third, fourth and fifth digits. The patient returned for regular follow-up visits for two years. The only complication was dehiscence of the left fourth digit incision site, possibly due to the wound being closed under excess tension. The dehiscence healed within two weeks and no recurrence was noted.
Multiple periungual fibromas caused by tuberous sclerosis occur in 25 percent of adults and young adults, and are highly specific for the disease with the onset generally occurring after adolescence.6 These fibromas can cause a great deal of discomfort and pain to the patient by placing pressure on the nail matrix and bone.7
Treatment is generally based on the extent of deformity and or invasion of the soft tissue structures surrounding the periungual fibromas.8 The recurrence rate of periungual fibromas is high and careful, aggressive resection is necessary to achieve permanent treament.7
In most cases, there is not much thought that goes into surgically removing these small benign tumors. However, in this case study, more planning was required. Due to the aggressive nature of the tumors, we needed to amputate part of the distal phalanges along with the fibromas. Without the partial amputation of the bone, closure of the wound could not have occurred.
When one is presented with aggressive periungual fibromas, the best option for treatment is to remove the tumors in total with partial amputation of the distal phalanx and nail bed in order to ensure wound closure and the best outcome for the patient.
Dr. Pontious is an Associate Professor in the Department of Podiatric Surgery at the Temple University School of Podiatric Medicine (TUSPM) in Philadelphia. She is a Fellow of the American College of Foot and Ankle Surgeons.