Finger Pain In A Professional Dog Groomer

Abstract

HISTORY: A 36-year-old right-handed female professional dog groomer with past medical history of PCOS, presents with a chief complaint of left hand digit 3 and 4 fingertip pain. She reports progressive discomfort for the past 10 months, worsened with tactile touch especially during work, and mildly improves with rest. Describes the pain as sharp electrical sensations rated 10/10 on pain scale, sensitive to cold weather. Outside facility workup included normal hand x-rays, cervical x-rays and a hand MRI. Electrodiagnostic/nerve conduction studies demonstrated mild carpal tunnel syndrome on the left without radiculopathy, for which she has tried a neutral wrist splint without improvement. She has been seen by her PCP, rheumatology, neurology, endocrinology, and orthopedic surgery, all without a confirmatory diagnosis. Her pain is now debilitating and thus she presents to Stanford for a 6th opinion. EXAM: On inspection no swelling or discoloration. Severe tenderness with light touch of digit 3 at the eponychial fold, ulnar side. Limited active and passive digit 3 DIP flexion due to pain. Sensation decreased in dorsal digital median nerve branch digits 3 and 4. Remaining strength and sensation in the hand intact. Phalen’s test at the wrist positive while tinel’s was negative. Spurling’s negative. DIFFERENTIAL: 1. Median or Palmar Digital Branch Mononeuropathy. 2. C7 Radiculopathy 3. Digital Collateral Ligament Injury 4. Tumor 5. Complex Regional Pain Syndrome 6. Mallet Finger 7. Raynaud’s Phenomenon RESULTS: Point-of-care ultrasound significant for digit 3 solitary hypoechoic lesion with clear boundaries and regular shape, and internal abundant hyperemia. Finger MRI showed 4 x 3 x 3 mm circumscribed T1 hypointense T2 hyperintense, enhancing lesion at dorsal aspect of the third distal phalanx. DIAGNOSIS: Glomus Tumor OUTCOME: Initiation of gabapentin, lidocaine cream for symptomatic relief and referral to orthopedics for definitive treatment with plans for left middle finger glomus tumor excision. The patient is currently pending surgery at the time of this submission, additional follow-up to be presented.