Case Report: Right Thumb Swelling

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.

1. What dual diagnosis is apparent from the physical exam and radiographic assessment?
2. What historical factors increase the risk of serious outcome?

1. Osteomyelitis with associate felon of the right thumb distal phalanx.
Patient age, diabetes, onychophagia (nail biting) and a previous injury/infection