Kevin S. Barlotta, MD
University of Alabama at Birmingham (UAB)
Chief Complaint: Right thumb pain and swelling
HPI: 55F insulin-dependent diabetic with a remote history of right thumbnail infection 3 weeks prior to presentation treated with local wound care and a course of oral antibiotics. The patient reported mild improvement initially, however, describes progressive symptoms and a new 4-day history of atraumatic right thumb pain and swelling. She denies fever and other skin and extremity complaints. She endorses onychophagia.
Physical Exam: 135/80 65. 18. 98.8. 97%
- General: Alert, no acute distress.
- Skin & Extremity: Distal aspect of the right thumb with swelling, erythema and a tense finger pad that is tender to palpation. Sensation intact. Flexion and extension of the interphalangeal joint intact. No lymphangitis.
Significant diagnostic results:
- Glucose: 142 mg/dL
- WBC 9.42 103/cmm
- ESR: 12 mm/hr
- CPR: 4.70 mg/L
- Gram stain:
- Gram positive cocci 2+
- White blood cells 2+
- Wound culture: Abundant Streptococcus constellatus.
Figure 1: R thumb
• Lateral view of patient’s right thumb demonstrating isolated erythema and edema over the distal digit.
Figure 2: R hand radiograph
• Erosive and destructive appearance of the distal phalanx of the thumb.
• Findings are concerning for osteomyelitis.
Questions:
1. What dual diagnosis is apparent from the physical exam and radiographic assessment?
2. What historical factors increase the risk of serious outcome?
Answers:
1. Osteomyelitis with associate felon of the right thumb distal phalanx.
Patient age, diabetes, onychophagia (nail biting) and a previous injury/infection