Seen in the ED: Progressive Isolated Finger Pain

Brady Pregerson, MD

Quiz

A man in his fifties presents with pain in a fingertip that has been getting increasingly worse. Notable on exam are a small scab on that finger and nail-bitten fingernails. Your Dx?

Patient history. A man in his early fifties presents to the emergency department (ED) for left middle finger pain. He is seen by the PA who thinks it’s an infection, perhaps an early felon but asks for your opinion. The pain has been gradually getting worse for about 2 weeks with occasional slight drainage. He denies any fever, trauma, or other complaints. Past medical history includes diabetes.

Vital signs & physical examination. Vital signs are normal. Physical exam is notable for “nail-bitten” fingernails and a firm fingertip on the left middle finger with some small scabs. See image below.

Initial diagnostic testing

Labs: WBC elevated at 12, glucose elevated at 215, CRP normal, rest of CBC and BMP normal

Imaging: X-ray results, normal; no evidence of osteomyelitis or foreign body

What is the most likely diagnosis?

A. Felon

B. Cellulitis

C. Frostbite

D. Digital ischemia

E. Herpetic whitlow


Digital Ischemia from The Emergency Medicine 1-Minute Consult Pocketbook