A Man With 10 Years of Exquisite Finger Pain

May 28, 2010

This case was submitted by Janaleigh Hoffman, MD, department of orthopedics, Kaiser Permanente Medical Center in Fremont, California, and Pearl X. Hu, MD, an orthopedic surgeon at the Permanente Medical Group, Kaiser Permanente Hospitals, Hayward and Fremont, California.

A 25-year-old man was seen in the orthopedic clinic with a complaint of severe, exquisite pain at the ulnar aspect of the distal phalanx of his dominant right index finger. The pain had been present for 10 years, but he had not sought treatment. There had been no major injury to his hand. The patient had diet-controlled diabetes mellitus and worked in a job involving computer use. Neither working on the keyboard nor frequently playing tennis produced symptoms. Only direct trauma to the area, such as with tapping directly on the painful spot on his finger, clapping his hands, or throwing a ball would produce marked pain. The patient reported no cold intolerance.

The results of physical examination of the patient’s index finger were remarkable only for marked pain to palpation at the ulnar border of the distal phalanx just adjacent to the base of the fingernail. A slight bluish dot appeared at the ulnar base of the fingernail.

An x-ray film (left) obtained of the patient’s right index finger showed mild chronic scalloping at the ulnar border of the distal phalanx (red arrow). An MRI scan of the same finger, obtained with contrast (right) and without contrast, showed a hyperintense T2 signal, hypointense T1 signal, and intense post-gadolinium enhancement (arrow) corresponding with the area of focal cortical scalloping seen on the x-ray film.

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A Man With 10 Years of Exquisite Finger Pain

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