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The most likely cause of pain and swelling in a fingertip is nail infection. When the symptoms persist, radiography is indicated.
A man of 28 consulted a general surgeon after six months of increasing pain in the right index finger. The provisional diagnosis was infection, but the symptoms persisted despite aspiration and subsequent excision of the nail. A radiograph was then obtained and the appearance suggested sclerosis of the terminal phalanx. An orthopaedic surgeon thought enchondroma the most likely diagnosis. Repeat X-rays with soft-tissue penetration then showed a cystic lesion of the terminal phalanx with surrounding sclerosis (Figure 1).
The lesion was excised and the histological diagnosis was osteoid osteoma. The patient was symptom-free 3 years later with good hand function.
A man of 24 sought advice with throbbing pain in the terminal phalanx of the left little finger. The symptoms had been troubling him for a year, and in the early stages an orthopaedic surgeon elsewhere had reassured him and recommended conservative management. He came to us because our hospital was nearer his workplace. Radiographs showed a cystic lesion with surrounding sclerosis in the distal part of the terminal phalanx, and a bone scan revealed a pathognomic ‘hot spot’ (Figure 2). The lesion was excised. Histological examination confirmed the diagnosis of osteoid osteoma. The pain ceased and he was symptom-free sixteen months postoperatively.
Lesions elsewhere cause painful scoliosis, joint pain and occasionally growth disturbances. With osteoid osteoma at the fingertips, nailbed infection is usually suspected at first. In our patients the mean delay in diagnosis was nine months. If the symptoms are mild or clinicians do not think of it, the delay can be much longer. Clinically, the classic features are pain, enlarged terminal phalanx and clubbing of the nail. The lesions seldom exceed 1.5 cm in diameter though reactive sclerosis can make them seem larger on the radiograph. The disproportionate amount of pain is probably due to the high vascularity and rich nerve supply.5,6 The swelling of the phalanges may be due to a combination of humoral substances secreted by the tumour, hyperaemia, release of inflammatory mediators and local hypoxia.7
Early in the clinical course, conventional radiographs are often normal.5 Soft-tissue exposure radiograph can be helpful in showing the nidus of the tumour with surrounding sclerosis, and in doubtful cases a technetium-99m bone scan is highly sensitive and specific.5,8