Ryan H. Fitzgerald DPM, FACFAS PRESENT RI Associate Editor Clinical Assistant Professor of Surgery-USC GHS Center for Amputation Prevention Greenville, SC

Case Presentation:
Bilateral Soft Tissue Masses

HPI: The patient is a 36 year-old female with a history of paraplegia who presents with lymphedema and a history of bilateral soft tissue masses that was admitted to the hospital for increasing drainage from the left foot mass. Due to the paraplegia, the patient has a care-giver who assists in her care and that provider related to noticing foul smelling drainage from the left foot location. The patient relates no history of trauma that she is aware of, and denies any recent history of fevers, chills, nausea, vomiting, chest pain, SOB, or any constitutional symptoms.

PMH: Paraplegia, Diabetes Mellitus, Lymphedema, Morbid Obesity

PSHx: Cholecystectomy, Appendectomy

Fam Hx: CAD, Diabetes

Vital Signs:

T:98.3, BP:130/84, HR 99, Pain: 0, Resp: 18, SPO2: 98% on Room Air

Physical Exam

The patient is alert and oriented; she demonstrates appropriate mood and affect, is morbidly obese and is in no apparent distress. Upon evaluation of the bilateral lower extremities, the patient demonstrates pedal pulses which are palpable and graded 2/4 at the dorsalis pedis and the posterior tibial arteries. There is evidence of bilateral lower extremity edema secondary to lymphedema and there is pitting noted. There is loss of protective sensation and no muscle function noted. The patient demonstrates evidence of soft tissue masses along the plantar aspect of the feet bilaterally. On the right foot (Figure 1) the patient demonstrates a soft tissue mass centrally along the plantar aspect of the midfoot and on the left foot, the patient demonstrates evidence of a mass inferior to the 4th digit in the area of the sulcus (Figure 2).

Figure 1

Figure 2

Radiographs

X-rays were obtained of the bilateral feet which demonstrated no acute osseous findings and no calcifications in the area of the soft tissue masses.

Considering the history and the clinical findings how would you proceed in the management of this patient? You can share your thoughts, insights and pearls here. We look forward to hearing from you, and will share part two of this case along with your comments next week.

All opinions expressed are my own and do not necessarily reflect those of my employer.

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