Intended for healthcare professionals

Endgames Case review

An unusual finger injury

BMJ 2016; 353 doi: (Published 25 May 2016) Cite this as: BMJ 2016;353:i2680
  1. David A Pettitt, doctoral research fellow and clinical fellow1 2,
  2. Ashwin Pai, clinical fellow1,
  3. Emma Bradbury, general practitioner1,
  4. Suresh Anandan, associate specialist in plastic and reconstructive surgery1,
  5. Mahendra Kulkarni, consultant plastic and reconstructive surgeon1
  1. 1Department of Plastic and Reconstructive Surgery, Wexham Park Hospital, Slough SL2 4L, UK
  2. 2Department of Paediatrics, University of Oxford, Oxford, UK
  1. Correspondence to: D A Pettitt dapettitt{at}

A 39 year old female farmer with no medical history presented to the emergency department with a painless swelling over her right index finger. The problem started two weeks earlier after she had been bitten by a lamb. After the injury the finger appeared “bruised.” This bruising continued and a swelling gradually developed. She reported no pain, changes in sensation, or reduced range of movement.

On clinical examination she was afebrile and haemodynamically stable. Her right index finger exhibited a full range of movement and was neurovascularly intact. The finger was not tender on direct palpation and it seemed to be the same temperature as her other fingers. The finger had a laceration on the radial aspect proximal to the nail fold, with a demarcated and raised area of reddish-blue discoloration measuring about 2 cm × 1.5 cm (fig 1). There was no palpable lymphadenopathy within the axilla.

Fig 1 Injured right index finger


  1. What are the differential diagnoses?

  2. What is the most likely diagnosis?

  3. What investigations might be ordered?

  4. How is this condition managed?


1. What are the differential diagnoses?

Short answer

Bruising (eg post-trauma), paronychia, herpetic whitlow, orf virus infection, Milker’s nodule, pyogenic granuloma, keratoacanthoma, and osteomyelitis.


Bruising is a common soft tissue injury (fig 2). It is often secondary to trauma and is characterised by a bluish or purple coloured patch as a result of underlying capillary damage. Bruising is typically painful initially and usually resolves within a few weeks, fading to a greenish-yellow colour before the skin finally returns to normal.

Fig 2 Bruising to the finger. Credit: Dr P Marazzi/Science Photo Library.SPL

In paronychia (fig 3) the infection generally starts in the paronychium at the side of the nail, with local redness, swelling, and pain. The lesion is tender …

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