PRESENT Residency Insight

Case Presentation
1st MPJ Discoloration - Follow Up Discussion

Here is the follow up piece to last week’s case discussion:

Thank you everyone for the responses to last week’s case presentation. The replies were abundant and most of you were at least partly correct. I have posted a few replies at the bottom of this note.

So, as most of you deciphered from the photo, this patient had prior bunion surgery. The painful prominence at dorsal 1st metatarsal was a cortical screw and the mysterious ‘horseshoe shaped’ discoloration at the tip of the arrow was indeed a retained piece of black monofilament NYLON SUTURE. According to the patient, her suture removal of several years ago had been very painful and difficult. From this I would conclude that this portion of the suture look was left behind during the attempted skin suture removal. Pictured below are photos showing the suture and screw removal.

CLICK IMAGE FOR CLOSEUP

John Steinberg, DPM
Editor - PRESENT

COMMUNITY FEEDBACK

This certainly is difficult to diagnose this pt. without any history. However, my initial thought would be to r/o Cutaneous Larvae Migrans.

Todd Rice, DPM
The Bryn Mawr Hospital
LindbergH31@Hotmail.COM

In my opinion this could be either subQ vicryl from a previous surgery or varicosities.

Gerald Mauriello Jr., DPM, MA
Caritas Health Care at St Johns Queens
gam47@columbia.edu

With regards to our mysterious horse-shoe shaped discoloration: on close-up this looks suspiciously like a staple. The stapler may have misfired and slipped under the epidermis as the remainder of the integument was re-approximated. Another possibility is that the doctor used a single ethibond stitch to re-approximate their capsulotomy/capsulorhaphy - it could be the case if the knot came undone and is now laying in a "staple" type orientation. This would also explain the green tinge.

Benjamin Marble, DPM
DVA - Salt Lake City
doctormarble@gmail.com

My guess is If she had any surgery before it should be: 1- Any foreign body reaction either to suture used or kind of metalosis for implant (screw? shape of staple?)

If not surgical case the best two options are: 1-superficial vein lesion (varicose)

2-some parasite

Diego Adarve, DPM
Jackson South Community Hospital
padys85@bellsouth.net

By looking at the picture I can decipher a couple of differentials. It is obvious that she had a previous procedure by way of her scar. It could be an engorged vein, thrombosis or hemangioma. Most likely it looks like a loop of PDS - the purple dyed kind. How long ago was her procedure?

Doug Pacaccio, DPM
pacman25@hotmail.com