Recurrent subungual exostosis of the thumb in a child

CASE REPORTS

Recurrent Subungual Exostosis of the Thumb in a Child

Tiago Santos Trindade¹, Diogo Gameiro¹, Miguel Costa², Cristina Alves¹, Inês Balacó¹.

¹Department of Pediatric Orthopaedics, Hospital Pediátrico de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal,
²Department of Pediatrics and Neonatology, Unidade Local de Saúde Entre Douro e Vouga, Santa Maria da Feira, Portugal.

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Abstract
Introduction: Subungual exostosis is a benign osteocartilaginous lesion that predominantly affects the toes and is uncommon in the pediatric population, particularly when involving the hand. Juxta-physeal localization in children poses diagnostic and therapeutic challenges due to recurrence risk and potential growth plate injury.
Case Presentation: We report the case of a 6-year-old girl presenting with a progressively enlarging subungual mass of the left thumb associated with nail deformity and minimal pain. Radiographic evaluation demonstrated a bony outgrowth arising from the dorsal aspect of the distal phalanx, consistent with subungual exostosis. Surgical excision was performed, and histopathology confirmed the diagnosis. Despite an uneventful postoperative course, radiographic recurrence occurred within the first year, with the lesion remaining juxta-physeal. Given the absence of pain or functional limitation, a conservative strategy with prolonged clinical and radiological surveillance was adopted. Progressive nail dystrophy persisted, but the patient remained functionally asymptomatic and well-adapted.
At 11 years of age, due to lesion progression and inflammatory changes, a second surgical excision was undertaken, achieving complete resection. Following physeal closure, no further recurrence was observed, and long-term follow-up demonstrated preserved thumb function with residual nail deformity.
Conclusion: This case highlights the high recurrence risk of subungual exostosis in skeletally immature patients and supports a cautious, individualized approach to management. Long-term follow-up is essential, and attention to functional and psychosocial outcomes is crucial in pediatric patients.

Why this article important?

Pediatric subungual exostosis of the hand is rare, and evidence guiding management of recurrent lesions near an open physis remains limited. This case provides a valuable long-term perspective on recurrence, treatment timing, and outcomes across childhood. It illustrates that recurrence does not necessarily mandate immediate reoperation when symptoms and function are preserved, supporting an individualized approach that balances surgical risks against clinical benefit. The report also emphasizes that treatment decisions should not rely solely on radiographic progression. Cosmetic concerns, nail dystrophy, self-image, and social well-being may become increasingly relevant as children grow older and should be incorporated into shared decision-making. By combining clinical, radiological, functional, and aesthetic considerations, this case offers practical lessons for clinicians managing rare benign tumors of the pediatric hand.

Summary of article

This case report describes an uncommon presentation of subungual exostosis of the thumb in a 6-year-old child, followed over five years until skeletal maturity. The juxta-physeal location posed a management challenge, as complete excision needed to be balanced against the risk of growth plate injury. Following initial surgery, radiographic recurrence developed, but because the patient remained pain-free and functionally unaffected, a conservative surveillance strategy was adopted. Definitive excision was performed only after lesion progression and inflammatory changes occurred. Long-term follow-up demonstrated preserved thumb function and no further recurrence after physeal closure. Beyond its surgical aspects, the case highlights the impact of persistent nail deformity on appearance and the importance of considering cosmetic and psychosocial outcomes alongside radiological findings when managing pediatric patients.

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