Sclerotic Fibroma On The Great Toe: A Case Report

HISTORY: A 45-year-old male presented to the outpatient orthopaedic clinic with a large mass located on the lateral aspect of the left hallux. The patient reported the mass was compressing his second toe causing discomfort with ambulation. The patient originally presented with this mass in 2020 with an initial MRI suggesting it was a mass of indeterminate origin. The patient deferred biopsy and surgery at that time. The patient reported that the mass had grown significantly since initial presentation, increasing in size from 2 cm in diameter by 1 cm in height to 4 cm in diameter by 3 cm in height. PHYSICAL EXAMINATION: Examination revealed a soft tissue mass on the lateral aspect of the left hallux that is well adhered to the underlying tissue without evidence of erythema, edema, or infection. The mass was mobile and well defined. The patient was nontender to palpation over the area of the mass. Gross sensation was intact over all digits of the left foot. Dorsalis pedis and tibialis posterior pulses were palpable 2/4. Capillary refill time was less than 3 seconds with pedal hair present. DIFFERENTIAL DIAGNOSIS: Benign neoplasms including lipoma, neurofibroma, and hemangioma. Malignant neoplasms including soft tissue sarcoma, lymphoma, and metastatic cancer. TESTS AND RESULTS: Anterior-posterior and lateral radiographs of left foot (2023): Well-defined soft tissue mass. Shadow of increased soft tissue density cortices appear normal on the distal and proximal phalanx. No bony involvement. No clinical or pathological fractures. MRI of left foot (2020): Indeterminate 17x15x15mm circumscribed hypointense exophytic subcutaneous lesion along the lateral aspect of the left first toe. No bony or tendinous involvement. Mild enhancement and edema along the left first toenail. No associated abscess appreciated. DIAGNOSIS: Benign fibrotic scleroma TREATMENT AND OUTCOMES: 1.Failure of conservative management including use of anti-inflammatory medications, changing shoe apparel, and use of shoe inserts. 2.Surgical removal with excisional biopsy at time of procedure. 3.Use of split thickness skin allograft placed during procedure. 4.Full weight bearing with use of surgical shoe and crutches after surgical intervention. 5.Rehabilitation starting 1 week after procedure. 6.Return to full activity 6-8 weeks after procedure.