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A 55 year old abattoir worker presented to the local minor injury unit with a two day history of pain and swelling of third web space of his left hand. He thought this might have been attributable to a thorn from a sheep's fleece breaking the skin. This was initially treated as a soft tissue infection with elevation, oral antibiotics and GP follow up. He returned two days later as there had been no improvement and was encouraged to continue with the treatment and to return if necessary.
He presented again two months later concerned that there was a foreign body in the same hand, which was again getting infected. Exploration under local anaesthetic was performed but no foreign body found, so the wound was packed and he was treated with further antibiotics and reviewed over the course of the next week.
He returned six weeks later as the wound had still not healed. At this stage he had a granulomatous lesion over the site of the initial injury that was thought initially to be a pyogenic granuloma. Ultrasound imaging of the area showed a hypoechoic area consistent with chronic inflammation and a linear hyperechoic structure measuring 4.25 mm thought to be a thorn or splinter (fig 1). The lesion was then explored under local anaesthesia and a pilonidal track found that was excised completely. It was filled with animal hairs. The wound was again packed and over the course of the next six weeks healed completely. The lesion was sent for histological examination, which showed evidence of acute and chronic inflammation.
Pilonidal sinuses of the hand are a recognised occupational hazard in hairdressers1 but there are no reports in the literature of similar cases in slaughtermen. It is a diagnosis to bear in mind in cases of non-healing infection. Clearly prompt recognition of the condition and definitive treatment on presentation would have allowed complete resolution in this case some four months earlier than actually happened. It may be sensible to follow up patients with hand infections until resolution has occurred. Ultrasound has not previously been widely used in the diagnosis of pilonidal disease but here was crucial to the diagnosis and we suggest that in similar cases early ultrasound scanning would allow a definitive diagnosis.
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