Practice Perfect 795
Mondor's Sign - More Than You Ever Wanted to Know

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Jarrod Shapiro, DPM, FACFAS, FACPM, FFPM, RCPS Glasg

Practice Perfect February 1, 2022

In patients with foot injuries, Mondor’s sign (ecchymosis on the plantar foot) is considered pathognomonic for fractures of the calcaneus. This sign is so easily recalled by students and residents that I must wonder if it’s true. Is Mondor’s sign really pathognomonic? Could it indicate any other injuries? Who is this Mondor anyway? Let’s explore Mondor’s sign.

Who Was Dr Mondor?

Henri Mondor, MD (1885 -1962) was a French physician who was apparently better known for his description of what later was called Mondor’s disease rather than the plantar bruising we know today. Mondor’s disease is a thrombophlebitis of the thoracoepigastric vein. It is a superficial thrombophlebitis, often self-limiting that may be involved with mammary cancers. This very interesting physician was one of the top surgeons of his day and worked at the famous Saltpetrière Hospital in Paris (where, coincidentally the one and only Jean Martin Charcot also worked – I love connections!). Unfortunately, Charcot died in 1893, at which time Mondor was only 8 years old, so they never met. 

I can’t help but have fun making a connection between Dr Mondor and Greek mythology. As I mentioned, Mondor’s disease is an inflammatory clotting disorder of the thoracoepigastric vein, but this vein is important for another reason. It is a connection between the femoral, axillary, and portal veins. Patients with liver cirrhosis or failure have venous congestion in the portal vein system leading to back flow into the superficial epigastric and thoracoepigastric veins, leading to distention of veins around the umbilicus and a sign called caput medusae, or Medusa’s head. Watch out! Don’t let her turn your liver to stone!

Improving Wound Care Outcomes and Utilizing Cyclical Topical Oxygen

Ron Guberman, DPM

Director of Podiatric Medical Education
Co-Chief, Podiatry Division, Dept of Surgery
Wyckoff Heights Medical Center
Brooklyn, NY

Ronald Guberman, DPM discusses the importance of a multidisciplinary, pragmatic and evidence-based approach to successful wound care outcomes. He also discusses oxygen requirements for cellular function including wound healing as well as the research supporting cyclical topical oxygen therapy and its advantages for treating wounds.

Available Credits: CPME 0.5

Is Mondor’s Sign Pathognomonic for Calcaneal Fractures?

The short answer is a simple “no.” It turns out that there is very little written about this sign. In fact, after much fruitless searching by yours truly, I was not able to determine why this is called Mondor’s sign at all. It’s distinctly possible that Henri Mondor didn’t characterize this sign at all. 

With that said, getting to the “no, it’s not pathognomonic” answer is straightforward since there are documented cases of what is termed the plantar ecchymosis sign in both Lisfranc¹ fracture dislocations and calcaneal fractures.² Now it appears logical to me that if it’s possible to see the same sign in two different traumatic diagnoses, then Mondor’s sign cannot be pathognomonic for calcaneal fractures. I would describe this in a slightly different way. Mondor’s sign appears to have a high sensitivity to foot injury but a lower specificity. Something pathognomonic should have a close to 100% specificity.

It appears the plantar ecchymosis sign is due, according to Richman and Barre, to the diffusion of blood in the central compartment of the foot.³ This makes logical sense if you think about the anatomy of the plantar aspect of the foot. First, we know that fluids follow the path of least resistance, so any injury with bleeding in the plantar foot will run along the plantar tissues deep to the plantar fascia until it finds another clear path. The medial and lateral intermuscular septae will keep the blood in the central compartment until that blood runs distally, coming to the area where the fascia splits as it runs toward the toes. This allows blood to end the less adherent subcutaneous tissue, creating the sign. Although there is no research evidence to confirm this, I suspect that any injury significant enough to cause deep bleeding in the plantar foot could produce Mondor’s sign. I also must wonder if there is an increased association between Mondor’s sign and compartment syndrome? I wouldn’t be surprised if this were true since excessive bleeding in a closed plantar space occurs in both situations. Unfortunately, I haven’t been able to find research evidence to support this hypothesis. There’s a research project for one of our intrepid young residents!

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Since we’re talking eponyms, colloquialisms, and interesting names for things, I couldn’t help leaving this conversation with one more name pertinent to calcaneal fractures, and that is the “lover’s fracture.” This could be my favorite colloquialism of all time. The lover’s fracture refers to an intraarticular joint depression fracture of the calcaneus, sustained – you guessed it! – when a suitor jumps out of a window to escape discovery during his or her secret tryst.⁴ Sounds like something from a Victorian British novel! I love it (pun intended)!

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]