Painful Fingertip Research Articles

Painful fingertip tumor in pregnancy

Painful fingertip tumor in pregnancy

The exquisitely painful fingertip – subungual glomus tumours

While most painful fingertips have a distinct causal history and/or associated symptoms, some can leave the practitioner at a loss during diagnosis. We present a rare differential that often has an indistinct history, subtle clinical signs and is commonly misdiagnosed, with average diagnosis time reported as 7 years 1. A 25-year-old patient presented with a several-year history of a gradually increasingly painful fingertip, just beneath her nail plate. There was no history of trauma or precipitating event she could recollect. She had been assessed by several practitioners over the years with normal radiology and ineffective neuromodulation, and analgesics offered little effect. On examination, she had a minimal area of slight blue discolouration under her nail plate, which elicited exquisite pain on palpation. This was diagnosed clinically as a subungual glomus tumour based on the symptom of exquisite pain in the fingertip without causal history and the subtle colour discolouration. Treatment was surgical excision under a digital nerve block with removal of the overlying nail plate. The lesion was characterised as a spot directly beneath the nail plate (Figure 1A), with a leash of proximal feeding vessels (Figure 1B). Excision was performed and the resulting defect closed directly (Figure 1C). Histology subsequently confirmed the clinical diagnosis of a glomus tumour, and on postoperative review, she was pain free. Glomus tumours were first described by Wood in 1812, with subsequent histological characterisation by Masson in 1924 2, 3. They are rare, typically benign tumours that arise from the neuromyoarterial structure of the glomus body, a structure believed to serve a thermoregulatory purpose 4. They account for 1–4·5% of hand tumours and are more common in women 1, 5. Although within the hand, the most common site being subungual, glomus tumours may also be found under the nail fold, nail matrix and within the pulp. They characteristically present with a triad of a tender, single, identifiable spot, which is hypersensitive to the cold and causes extreme pain 2. Two clinical tests, with high specificity, are commonly used to aid diagnosis: Love and Heldrith's tests. “Love's test” describes using a small rounded tip, such as a ball point pen nib, to press against the lesion eliciting exquisite pain. “Heldrith's test” involves raising the arm above heart level to exsanguinate the limb prior to inflation of a blood pressure cuff over the upper arm. The patient may experience symptomatic relief during this phase. The pressure cuff is then released, and pain is instantly elicited in the fingertip with a positive test 1, 6. Magnetic resonance imaging and ultrasound scanning have been shown to play a role in delineating the extent and location of the tumour, although this is not clinically indicated 7. In summary, when presented with a patient who has an extremely painful fingertip and an unclear history, never forget the rare but debilitating glomus tumour and refer the patient on to a hand surgeon for further management.

Classic porokeratosis of Mibelli.

A 47-year-old homemaker presented with recurrent ulcer over left palm and mildly painful fingertip swelling over left thumb and middle finger for past 1 year. She had noticed ring like skin lesion over her left palm since childhood. There was no family history of similar skin lesion. On examination, multiple annular plaques with central atrophy and keratotic ridge at the margin were seen over left side of face, lips, neck, upper back, abdomen, left forearm and left palm. Over the palm, the keratotic ridge ran over thenar and hypothenar eminence, base of fingers, first finger web space and along the thumb and middle finger causing constriction band with bulbous swelling distally at finger tips [Figure 1]; and nails of the two fingers were dystrophic at the sites adjoining the ridges [Figure ​[Figure2a2a-​-c].c]. Annular plaque with keratotic ridge was seen over the left eyelid margins, left side of lower lip involving the mucosal surfaces of lip and lower eyelid and right side buccal mucosa. However, she did not have any discomfort in the oral cavity or eye. There was fissuring at the site of ridge over thenar eminence of left palm [Figure 1]. On dermoscopy, the ridge of the annular plaques was prominently seen along with a thin groove in the keratotic ridge [Figure 2d]. Radiography of the affected hand revealed distal digital narrowing in the left thumb [Figure 2e]. Histopathology from the ridge showed keratin-filled epidermal invaginations [Figure 3]. There was no evidence of malignancy from the biopsy taken from the fissure or the bulbous projection. Patient was started on acitretin and planned for CO2 laser ablation of the lesions. Figure 1 Plaque with central atrophy and threadlike keratotic ridge at the margin over the palm, first finger web space, along the thumb and middle finger causing constriction band with bulbous swelling distally at finger tips Figure 2 (a and b) dystrophic nails of the thumb and middle finger with adjoining keratotic ridges, (c) keratotic ridge at adjoining sites of thumb and index finger, (d) its dermoscopic image showing the groove in the keratotic ridge and (e) radiographic image ... Figure 3 Keratin-filled epidermal invagination with rising parakeratotic column (H and E ×40) and inset showing higher magnification of keratin filled epidermal invaginations with irregularly arranged keratinocytes with pyknotic nuclei (H and E ×200) ...

Effects of Music Engagement on Responses to Painful Stimulation

We propose a theoretical framework for the behavioral modulation of pain based on constructivism, positing that task engagement, such as listening for errors in a musical passage, can establish a construction of reality that effectively replaces pain as a competing construction. Graded engagement produces graded reductions in pain as indicated by reduced psychophysiological arousal and subjective pain report. Fifty-three healthy volunteers having normal hearing participated in 4 music listening conditions consisting of passive listening (no task) or performing an error detection task varying in signal complexity and task difficulty. During all conditions, participants received normally painful fingertip shocks varying in intensity while stimulus-evoked potentials (SEP), pupil dilation responses (PDR), and retrospective pain reports were obtained. SEP and PDR increased with increasing stimulus intensity. Task performance decreased with increasing task difficulty. Mixed model analyses, adjusted for habituation/sensitization and repeated measures within person, revealed significant quadratic trends for SEP and pain report (Pchange<0.001) with large reductions from no task to easy task and smaller graded reductions corresponding to increasing task difficulty/complexity. PDR decreased linearly (Pchange<0.001) with graded task condition. We infer that these graded reductions in indicators of central and peripheral arousal and in reported pain correspond to graded increases in engagement in the music listening task. Engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. Better understanding of these processes will advance the development of more effective pain modulation through improved manipulation of engagement strategies.

Painful fingertip swelling of the long finger

A 35-year-old Caucasian woman presented with a 14-month history of relapsing painful fingertip swelling of the left middle finger observed after a minor trauma. Conventional radiographs (Fig. 1) were performed at presentation. After failure of conservative treatment, the patient underwent initial surgery without success. Follow-up MRI (Fig. 2) and CT (Fig. 3) were obtained at our institution 6 months after the first surgical procedure (Figs. 1a–b, 2a–d, 3 and 4). Funding None

Painful fingertip swelling of the middle finger

Osteoid osteoma (OO) is a benign bone-forming tumour that accounts for about 12% of benign and 3% of all bone neoplasms [1]. It mainly affects patients during childhood or early adulthood, with a male preponderance. Despite its predilection for the long bones of the lower limbs, this tumour can occur in any bone of the skeleton and may be found in the hand and wrist in up to 10% of cases [2]. However, OOs of the distal phalanx are relatively uncommon, with only a few case series reported in the English literature so far [3–5]. The diagnosis of distal phalangeal OO is challenging for several reasons. First, the typical clinical features may not be present [2, 3, 5]. Pain may not be worse at night, or be relieved by aspirin. Moreover, soft-tissue swelling and erythema, as well as nail deformities, may mislead the physician. Second, its imaging characteristics (i.e. a small radiolucent lesion with central calcification, peripheral sclerosis and periosteal reaction [1]) may also be atypical [3–6]. Because of the presence of thickened Sharpey’s fibres, a periosteal reaction is rarely found in the distal phalanx [6]. Besides, endosteal sclerosis may be counterbalanced by local osteopaenia. Furthermore, other bony lesions of the fingertips, such as chronic osteomyelitis, epidermoid cyst, enchondroma or glomus tumour, may mimic an OO [3, 5, 6]. Zampa et al. recently reported the added value of dynamic contrast-enhanced MR imaging for OO in atypical locations, in terms of nidus conspicuity and diagnostic confidence [7]. Third, the histological features may even be unusual [5]. All those reasons could explain the delay, sometimes of several months to years, in the diagnosis and the treatment of phalangeal OOs. The main clinical differential diagnosis of painful fingertip swelling includes whitlow or paronychia, osteomyelitis, glomus tumour, subungual exostosis, arthritis and OO [3, 5, 6]. In our case, conventional radiographs (see Fig. 1 in the Question), ultrasound and previous CT and MR imaging studies (all not shown) barely displayed a focal lesion at the base of the distal phalanx. Follow-up MRI, performed at our institution several months after the onset of symptoms and after failure of initial surgery, demonstrated persisting diffuse inflammatory changes of the distal and middle phalanges as well as in the The case presentation can be found at doi:10.1007/s00256-011-1218-z

Surgical Debridement of Painful Fingertip Calcinosis Cutis in CREST Syndrome

Painful fingertip calcinosis cutis causes substantial morbidity in patients with CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia), also called limited cutaneous scleroderma. Medical therapy for this condition is uniformly disappointing.

A psychophysiological causal model of pain report validity

The validity of the pain report is vitally important but difficult to assess because pain is a personal experience. Human laboratory research affords an opportunity to investigate validity because one can measure the consistency and sensitivity of pain ratings produced in response to known stimuli. This article presents 2 levels of evidence characterizing the validity of the pain report measure. The within-subject agreement of pain report with known stimulus variation quantifies the criterion validity, or accuracy, of the measure. Causal modeling defines a second, between-subject, level of construct validity by suggesting a psychophysiological mechanism determining the observed individual variation in accuracy. We analyzed pain rating data obtained in a laboratory study where 100 subjects (56 men and 44 women) experienced varied levels of painful fingertip electrical stimulation, delivered in random order across 144 trials. Unknown to the subjects, there were only 3 stimulus intensities. Accuracy, defined operationally as the proportion of variance in pain report explained by stimulus level, ranged from 0.07 to 0.91 with a median of 0.64. Hypothesized determinants of accuracy comprised current intensity, event-related late near field evoked potentials, skin conductance response, heart rate, and pupil diameter change. We limited the evoked potential measures to the amplitude of the negative peak at 150 msec (N150amp) and combined the latter 3 measures to form a single index of overall sympathetic nervous system arousal (Arousal). Although men chose higher stimulus levels for the experiment and had higher Arousal than did women, their mean pain reports and their Accuracy did not differ from those of female subjects. We constructed a sequence of path analysis models designed to clarify the causal contributions of current intensity, N150amp, and Arousal, and to determine whether these relationships differ in men and women. The final model revealed a direct causal chain. Stimulus current determined the amplitude of N150amp (possibly an indicator of attention). N150amp in turn determined Arousal, and Arousal emerged as the sole determinant of the Accuracy of the pain report. In addition, this latter effect differed across the sexes. Men who experienced higher levels of Arousal gave more accurate pain reports than those who had lower levels, but women who had higher levels of Arousal gave less accurate pain reports than those with lower levels. Thus construct validation emerged, not from direct stimulus-response correlation, but from the elucidation of a causal chain that related stimulus to response. © 2002 by the American Pain Society