Paroxysmal finger hematoma | Cleveland Clinic Journal of Medicine

The Clinical Picture

Daan J.L. van Twist, MD, PhD, Wim Hermans and Guy J.M. Mostard, MD

Cleveland Clinic Journal of Medicine April 2020, 87 (4) 194; DOI: https://doi.org/10.3949/ccjm.87a.19122

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A previously healthy 51-year-old woman reported recurrent episodes of blue discoloration of one or more fingers associated with pain and swelling and mainly affecting the intermediate phalanges of the fourth finger of each hand. During some episodes, the second and third fingers were also involved. Each time, the symptoms resolved spontaneously within 3 days.

She reported no other complaints and no recurrent trauma, spontaneous bleeding, palpitations, or discoloration of the fingers when exposed to cold. She was a nonsmoker.

Results of the physical examination were normal, including brachial and finger blood pressures, measured at the proximal phalanx of each finger, and Doppler studies of the brachial, radial, ulnar, and digital arteries. Other laboratory tests showed no signs of underlying inflammatory, hematologic, or coagulation disorder.

Based on the results of the evaluation, the patient’s condition was diagnosed as paroxysmal finger hematoma.

PAROXYSMAL FINGER HEMATOMA

Paroxysmal finger hematoma, also known as Achenbach syndrome, is a benign, self-limiting condition that predominantly affects middle-aged women.¹ It is characterized by recurrent spontaneous subcutaneous bleeding in the fingers, typically on the palmar surface, mainly around the proximal interphalangeal joint creases. The cause is unknown, but local vascular fragility has been suggested.

Although relapses may frequently occur, no treatment is indicated, as the symptoms resolve spontaneously within a few days.

The diagnosis is based on the typical clinical presentation, as results of routine laboratory testing and Doppler studies of the arteries of the arm are usually normal.² Therefore, it does not require further testing if the clinical presentation is typical and there are no clinical clues for an underlying disease such as Raynaud phenomenon, autoinflammatory disease, or thromboembolism.

Figure 1

The patient reported recurrent episodes of blue discoloration of the palmar surface of the fingers, associated with pain and swelling. The symptoms usually resolved within 3 days.

Unfortunately, the typical symptoms are often not recognized, resulting in unnecessary and potentially harmful diagnostic procedures such as tissue biopsy and catheter-based angiography. Hence, awareness of this benign, self-limiting syndrome is important.

REFERENCES

1. ↵
   1. Godoy A,
   2. Tabares AH

   . Achenbach syndrome (paroxysmal finger hematoma). Vasc Med 2019; 24(4):361–366. doi:10.1177/1358863X19849627

2. ↵
   1. Aida F,
   2. Kasimzade F

   . Analysis of 24 patients with Achenbach’s syndrome. World J Clin Cases 2019; 7(10):1103–1110. doi:10.12998/wjcc.v7.i10.1103

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Achenbach syndrome (paroxysmal finger hematoma)

Review

. 2019 Aug;24(4):361-366.

doi: 10.1177/1358863X19849627.

Epub 2019 Jun 4.

Alejandro Godoy 
¹
, Aldo Hugo Tabares 
^1
 
2

Affiliations

Affiliations

• ¹ 1 Thrombosis and Vascular Medicine Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina.
• ² 2 Instituto de Ciencias Biomédicas de Córdoba (IUCBC), Hospital Privado Universitario de Córdoba, Córdoba, Argentina.

• PMID:

  31159682

• DOI:

  10. 1177/1358863X19849627

Review

Alejandro Godoy et al.

Vasc Med.

2019 Aug.

. 2019 Aug;24(4):361-366.

doi: 10.1177/1358863X19849627.

Epub 2019 Jun 4.

Authors

Alejandro Godoy 
¹
, Aldo Hugo Tabares 
^1
 
2

Affiliations

• ¹ 1 Thrombosis and Vascular Medicine Service, Hospital Privado Universitario de Córdoba, Córdoba, Argentina.
• ² 2 Instituto de Ciencias Biomédicas de Córdoba (IUCBC), Hospital Privado Universitario de Córdoba, Córdoba, Argentina.

• PMID:

  31159682

• DOI:

  10.1177/1358863X19849627

Abstract

Achenbach syndrome (paroxysmal finger hematoma) refers to a condition in which a patient exhibits episodic pain and swelling in one or more digits along with the subsequent appearance of a hematoma on the palmar side of the proximal phalanges. Achenbach syndrome is a benign condition of unknown etiology in which prodromal symptoms, such as pain, tingling, and itching, may occur from minutes to hours before the color change appears. The subdermal bleeding usually stops spontaneously or after local pressure is applied. The color changes usually disappear within a few days, without permanent sequelae. The diagnosis of Achenbach syndrome is based strictly on its clinical features because the results of all routine investigations are usually normal. Physicians should become aware of this condition in order to advise their patients about its benign prognosis and to avoid unnecessary testing.

Keywords:

Achenbach syndrome; blue finger; paroxysmal finger hematoma; purple digit; venous hemorrhage.

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MeSH terms

Finger bruise – causes, symptoms, diagnosis and treatment

Finger bruise is a closed traumatic injury to the soft tissues of the finger of the upper or lower extremity. Trauma usually occurs in everyday life as a result of a blow. It is manifested by swelling, cyanosis, sharp pain and limitation of movements. When hitting the nail phalanx, subungual hematomas are sometimes formed. According to clinical symptoms, a finger bruise may resemble a fracture; X-rays are prescribed to confirm the preservation of the integrity of the bone. Treatment is usually conservative, in the presence of a large subungual hematoma, an autopsy is indicated.

General information

Finger bruising is classified as minor traumatic injury. This injury occupies one of the first places among the reasons for going to emergency rooms. Symptoms of a bruised finger are similar to those of a fracture, therefore, to exclude serious damage in such injuries, it is imperative to consult a doctor.

In some cases, a bruise of the nail phalanx of the finger is accompanied by a rupture of the extensor tendon or its detachment from the place of attachment. With early treatment in such cases, it is usually possible to do without surgery, in the long-term period, surgical interventions are required, which is another serious argument in favor of visiting a doctor in the first hours after an injury. The treatment of finger bruises is carried out by doctors specializing in traumatology and orthopedics.

Bruised finger

Causes

Usually occurs in everyday life. The fingers of the hand suffer when hit by a heavy object (for example, a hammer), work in the country, pinching a finger between various hard surfaces, for example, between a door and a jamb. Toe bruises are formed when heavy objects fall on the foot or when hitting hard objects (on the leg of a chair, on the jamb). Damage may also occur during work or sports.

Pathogenesis

The fingers are made up of small tubular bones connected by movable joints. The first fingers have two phalanges, the rest have three phalanges. The bones are surrounded by a layer of fiber, along the dorsal and palmar (on the foot – plantar) surfaces of the fingers there are tendons that attach to the nail and middle phalanges. The fingers are a highly differentiated organ designed by nature to perform very precise and complex movements. This causes their rich blood supply and innervation.

Small blood vessels and nerves suffer from injury. Vessels rupture, blood is poured into soft tissues. Due to swelling and hemorrhage, the nerve endings are compressed, which leads to an intense pain syndrome. The situation is aggravated by the fact that the skin of the fingers (especially their palmar surface) is dense, little prone to stretching. Because of this, areas of high pressure are created in the tissues, which leads to increased pain.

The toes are not so well supplied with blood and innervated, however, the distal parts of the foot bear a large load during standing and are involved in the roll of the leg during walking, which causes a noticeable violation of support and movement even with minor bruises of the fingers. The skin of this anatomical zone is even denser than on the palmar surface of the fingers, therefore bruises of the toes are also accompanied by an increase in local pressure, the formation of foci of tension in the tissues and compression of nerve endings with the development of severe pain.

Symptoms

Finger bruises

The patient complains of pain in the finger area. In the anamnesis, a characteristic injury is revealed: a blow to the finger, pinching of the finger between solid objects, etc. The finger is edematous, the skin is cyanotic, sometimes with a purple tint. Under the nail bed or in the thickness of the skin, small hematomas can be detected.

With subungual hematomas, due to the formation of a high pressure zone, the pain becomes more intense, jerking or bursting, resembling pain in purulent processes. The feeling is painful. Rough deformation and violation of anatomical relationships are not observed. There is no bone crunch, there is no pathological mobility. Movement is usually limited, but possible.

Sometimes a blow to the end of the finger or a fall on a straightened finger in the region of the nail phalanx simultaneously with a bruise causes a subcutaneous rupture of the extensor tendon, which may be complete or incomplete. With an incomplete break, the movements are partially preserved, but full extension becomes impossible. With a complete rupture, due to the bent nail phalanx, the finger takes on the appearance of a “hammer”, there are no extensor movements.

Bruised toes

A patient with a bruised toe complains of pain in the injured area. The anamnesis reveals a fall of a heavy object on the foot or a toe hit on a hard object. Immediately after the injury, the pain syndrome is intense, in the next few hours the pain decreases, and as the edema increases, it increases again. The finger is enlarged, cyanotic. With a bruise of the nail phalanx, subungual hematomas are often detected. Movements are limited, while supporting the patient tries to step on the heel without loading the forefoot.

Diagnosis

The diagnosis is made by a traumatologist. An important task of the diagnostic stage is to exclude a more severe injury – a broken finger. Differentiation with dislocations is usually not required, since with bruises there is no characteristic deformation with displacement of one phalanx relative to the other. To clarify the diagnosis and the final exclusion of a fracture, apply:

• External examination . The finger is slightly or moderately swollen, bruises and hematomas are possible. The symptom of axial load is negative, pathological mobility and bone crepitus are absent.
• Imaging techniques . A finger x-ray is usually ordered. Young children who have small bones that are difficult to see on normal x-rays sometimes have a CT scan of the hand or foot. According to additional studies, pathological changes in bone structures are not detected.

Diagnosis of tendon rupture is made on the basis of physical examination, no additional tests are required. The presence of a rupture is indicated by the typical position of the nail phalanx, the impossibility of complete extension (with partial damage) or movements (with complete detachment of the tendon).

Treatment

First aid

First aid for bruised fingers is simple. If there is a ring on the finger, it must be removed immediately, because due to the increasing edema, this will subsequently become impossible. Ice should be applied to the finger or substitute it under a stream of cold water. Cold water can only be used as a remedy for acute pain, wetting the finger for a long time (for example, doing cold compresses) is not recommended, this will negatively affect the skin.

An ice pack will help to narrow the blood vessels, reduce hemorrhages and prevent the occurrence of severe edema. If there are small wounds or abrasions in the finger area, they must be treated with iodine or brilliant green. It is not required to prophylactically “cover up” the entire finger, trying to protect it from the penetration of infection – this will only complicate the examination of the traumatologist.

In case of partial detachment of the nail plate, wash the wound and apply a bandage to avoid further trauma. It is not necessary to fix the torn part of the nail plate with adhesive plaster – this increases the risk of its tearing off when the bandage is removed. It is also not necessary to try to open hematomas. After providing first aid, the patient is taken to the emergency room to exclude more severe injuries (fractures, dislocations).

At the stage of first aid for a bruised toe, the same measures are taken as for a bruised toe: cold, elevated position of the limb, treatment of abrasions with brilliant green or iodine. It should be borne in mind that small wounds on the legs suppurate more often than on the hands, so the finger must be thoroughly rinsed under running water to remove dirt from the abrasions. You should not open hematomas on your own. Seek medical attention immediately after an injury to rule out more serious injury.

Specialized treatment

Finger bruises are treated on an outpatient basis. Intradermal hematomas are opened, with small subungual hematomas, the nail is pierced with a needle, releasing the accumulated blood. Large subungual hematomas may require removal of the nail. The patient is advised not to load the hand, if possible, keep it in an elevated position and apply cold first, and then dry heat. Painkillers are usually not required, with severe pain, you can take analgin, ketorolac, or any other analgesic once. The period of disability ranges from 1 to 2-3 weeks.

In case of subcutaneous rupture of the extensor tendon, immediately after the injury, a plaster splint or a special bandage is applied, fixing the straightened finger in a state of hyperextension. In some cases, immobilization of the finger is carried out, keeping the middle phalanx in the flexion position, and the nail in the extension position. The immobilization period is 4 weeks. If after this period active extension of the finger remains impossible, surgical treatment is indicated – a tendon suture followed by fixation with a Kirschner wire or a plaster splint.

Treatment of bruised toes is outpatient in the emergency room. Subcutaneous and subungual hematomas are opened, with large subungual hematomas, the nail plate is removed and an aseptic bandage is applied. With mild bruises, it is recommended to step on the foot less and maintain an elevated position of the limb. With severe bruises of several fingers, in some cases, plaster is applied to ensure the rest of the affected segment. In acute pain, it is recommended to take analgesics. The patient is referred to UHF. The term of disability is usually 1-3 weeks.

Prognosis and prevention

Favorable prognosis. All symptoms completely disappear within one or several weeks, there are no residual effects. In the presence of large hematomas, the duration of the recovery period may increase. Prevention consists in the implementation of measures to prevent domestic and industrial injuries.

Finger bruise – causes, symptoms, diagnosis and treatment

Finger bruise is a closed traumatic injury to the soft tissues of the finger of the upper or lower extremity. Trauma usually occurs in everyday life as a result of a blow. It is manifested by swelling, cyanosis, sharp pain and limitation of movements. When hitting the nail phalanx, subungual hematomas are sometimes formed. According to clinical symptoms, a finger bruise may resemble a fracture; X-rays are prescribed to confirm the preservation of the integrity of the bone. Treatment is usually conservative, in the presence of a large subungual hematoma, an autopsy is indicated.

General information

Finger bruising is classified as minor traumatic injury. This injury occupies one of the first places among the reasons for going to emergency rooms. Symptoms of a bruised finger are similar to those of a fracture, therefore, to exclude serious damage in such injuries, it is imperative to consult a doctor.

In some cases, a bruise of the nail phalanx of the finger is accompanied by a rupture of the extensor tendon or its detachment from the place of attachment. With early treatment in such cases, it is usually possible to do without surgery, in the long-term period, surgical interventions are required, which is another serious argument in favor of visiting a doctor in the first hours after an injury. The treatment of finger bruises is carried out by doctors specializing in traumatology and orthopedics.

Bruised finger

Causes

Usually occurs in everyday life. The fingers of the hand suffer when hit by a heavy object (for example, a hammer), work in the country, pinching a finger between various hard surfaces, for example, between a door and a jamb. Toe bruises are formed when heavy objects fall on the foot or when hitting hard objects (on the leg of a chair, on the jamb). Damage may also occur during work or sports.

Pathogenesis

The fingers are made up of small tubular bones connected by movable joints. The first fingers have two phalanges, the rest have three phalanges. The bones are surrounded by a layer of fiber, along the dorsal and palmar (on the foot – plantar) surfaces of the fingers there are tendons that attach to the nail and middle phalanges. The fingers are a highly differentiated organ designed by nature to perform very precise and complex movements. This causes their rich blood supply and innervation.

Small blood vessels and nerves suffer from injury. Vessels rupture, blood is poured into soft tissues. Due to swelling and hemorrhage, the nerve endings are compressed, which leads to an intense pain syndrome. The situation is aggravated by the fact that the skin of the fingers (especially their palmar surface) is dense, little prone to stretching. Because of this, areas of high pressure are created in the tissues, which leads to increased pain.

The toes are not so well supplied with blood and innervated, however, the distal parts of the foot bear a large load during standing and are involved in the roll of the leg during walking, which causes a noticeable violation of support and movement even with minor bruises of the fingers. The skin of this anatomical zone is even denser than on the palmar surface of the fingers, therefore bruises of the toes are also accompanied by an increase in local pressure, the formation of foci of tension in the tissues and compression of nerve endings with the development of severe pain.

Symptoms

Finger bruises

The patient complains of pain in the finger area. In the anamnesis, a characteristic injury is revealed: a blow to the finger, pinching of the finger between solid objects, etc. The finger is edematous, the skin is cyanotic, sometimes with a purple tint. Under the nail bed or in the thickness of the skin, small hematomas can be detected.

With subungual hematomas, due to the formation of a high pressure zone, the pain becomes more intense, jerking or bursting, resembling pain in purulent processes. The feeling is painful. Rough deformation and violation of anatomical relationships are not observed. There is no bone crunch, there is no pathological mobility. Movement is usually limited, but possible.

Sometimes a blow to the end of the finger or a fall on a straightened finger in the region of the nail phalanx simultaneously with a bruise causes a subcutaneous rupture of the extensor tendon, which may be complete or incomplete. With an incomplete break, the movements are partially preserved, but full extension becomes impossible. With a complete rupture, due to the bent nail phalanx, the finger takes on the appearance of a “hammer”, there are no extensor movements.

Bruised toes

A patient with a bruised toe complains of pain in the injured area. The anamnesis reveals a fall of a heavy object on the foot or a toe hit on a hard object. Immediately after the injury, the pain syndrome is intense, in the next few hours the pain decreases, and as the edema increases, it increases again. The finger is enlarged, cyanotic. With a bruise of the nail phalanx, subungual hematomas are often detected. Movements are limited, while supporting the patient tries to step on the heel without loading the forefoot.

Diagnosis

The diagnosis is made by a traumatologist. An important task of the diagnostic stage is to exclude a more severe injury – a broken finger. Differentiation with dislocations is usually not required, since with bruises there is no characteristic deformation with displacement of one phalanx relative to the other. To clarify the diagnosis and the final exclusion of a fracture, apply:

• External examination . The finger is slightly or moderately swollen, bruises and hematomas are possible. The symptom of axial load is negative, pathological mobility and bone crepitus are absent.
• Imaging techniques . A finger x-ray is usually ordered. Young children who have small bones that are difficult to see on normal x-rays sometimes have a CT scan of the hand or foot. According to additional studies, pathological changes in bone structures are not detected.

Diagnosis of tendon rupture is made on the basis of physical examination, no additional tests are required. The presence of a rupture is indicated by the typical position of the nail phalanx, the impossibility of complete extension (with partial damage) or movements (with complete detachment of the tendon).

Treatment

First aid

First aid for bruised fingers is simple. If there is a ring on the finger, it must be removed immediately, because due to the increasing edema, this will subsequently become impossible. Ice should be applied to the finger or substitute it under a stream of cold water. Cold water can only be used as a remedy for acute pain, wetting the finger for a long time (for example, doing cold compresses) is not recommended, this will negatively affect the skin.

An ice pack will help to narrow the blood vessels, reduce hemorrhages and prevent the occurrence of severe edema. If there are small wounds or abrasions in the finger area, they must be treated with iodine or brilliant green. It is not required to prophylactically “cover up” the entire finger, trying to protect it from the penetration of infection – this will only complicate the examination of the traumatologist.

In case of partial detachment of the nail plate, wash the wound and apply a bandage to avoid further trauma. It is not necessary to fix the torn part of the nail plate with adhesive plaster – this increases the risk of its tearing off when the bandage is removed. It is also not necessary to try to open hematomas. After providing first aid, the patient is taken to the emergency room to exclude more severe injuries (fractures, dislocations).

At the stage of first aid for a bruised toe, the same measures are taken as for a bruised toe: cold, elevated position of the limb, treatment of abrasions with brilliant green or iodine. It should be borne in mind that small wounds on the legs suppurate more often than on the hands, so the finger must be thoroughly rinsed under running water to remove dirt from the abrasions. You should not open hematomas on your own. Seek medical attention immediately after an injury to rule out more serious injury.

Specialized treatment

Finger bruises are treated on an outpatient basis. Intradermal hematomas are opened, with small subungual hematomas, the nail is pierced with a needle, releasing the accumulated blood. Large subungual hematomas may require removal of the nail. The patient is advised not to load the hand, if possible, keep it in an elevated position and apply cold first, and then dry heat. Painkillers are usually not required, with severe pain, you can take analgin, ketorolac, or any other analgesic once. The period of disability ranges from 1 to 2-3 weeks.

In case of subcutaneous rupture of the extensor tendon, immediately after the injury, a plaster splint or a special bandage is applied, fixing the straightened finger in a state of hyperextension. In some cases, immobilization of the finger is carried out, keeping the middle phalanx in the flexion position, and the nail in the extension position.