Arthrodesis of distal interphalangeal and thumb interphalangeal joint: a retrospective cohort study of 149 cases

BACKGROUND

Arthrodesis of finger joints is often the last line of treatment of severe pain due to osteoarthritis, rheumatoid arthritis, or mallet finger. At the Department of Orthopedic and Hand Surgery, Örebro University Hospital (ÖUH) in Sweden, the Kirschner-wire technique was standard until 2020, when the headless compression screw technique was introduced as a complement. There is no consensus on which method is superior. The purpose of this study was to examine the outcomes and complications associated with distal interphalangeal (DIP) joint and thumb interphalangeal (IP) joint arthrodesis, and to see whether these correlated with patient-dependent and treatment-related factors.

METHODS

In a retrospective cohort study, we evaluated a total of 149 consecutive arthrodeses (118 DIP joint and 31 thumb IP joint) performed between 2012 and 2022. The primary outcome was risk factors for complications after arthrodesis.

RESULTS

Osteoarthritis was the most common indication (56%) for arthrodesis. The majority of the patients were females (74%), and the median age was 62 (range 18-86). The complication frequency was 35%, with infection being the most common (25%). Time to completed follow up was < 12 weeks in the majority of the cases (58%). There were no significant differences in complication rate between the 136 joints operated using Kirschner wire and the 13 joints operated using headless compression screws. There was no significant increased risk of complications among smokers or patients with rheumatoid arthritis. Diabetes and surgeon experience had a significant influence on the risk of complication (p = 0.036 and p = 0.006, respectively).

CONCLUSIONS

Osteoarthritis was the most common indication for arthrodesis and postoperative complications occurred at a rate similar to that reported in the existing literature. Diabetes and surgeon experience were identified as factors increasing the risk of postoperative complications in these DIP/thumb IP joint arthrodeses. However, there was no significant difference between the two techniques (Kirschner wire and headless compression screws) regarding complications. Further studies are needed in order to determine the optimal type of operation and choice of implant.

TRIAL REGISTRATION

Researchweb CRIS #280,998, 26th of July 2023.

Quick and safe: why a k-wire-extension-block-fixation of a bony mallet finger is the favoured treatment

INTRODUCTION

Mallet fingers are the most common tendon injuries of the hand. Bony avulsion distal finger extensor tendon ruptures causing a mallet finger require special attention and management. In this monocentral study, we analyzed the clinical and individual outcomes succeeding minimal invasive k-wire extension block treatment of bony mallet fingers.

MATERIALS AND METHODS

In a retrospective study, we sent a self-designed template and a QUICK-DASH score questionnaire to all patients, who were treated because of a bony mallet finger between 2009 and 2022 and fulfilled the inclusion criteria. A total of 244 requests were sent out. 72 (29.5%) patients participated in the study. Forty-five men and twenty-seven women were included.

RESULTS

98.7% (n = 75) of the cases were successfully treated. Patients were highly satisfied with the treatment (median 8.0; SD ± 2.9; range 1.0-10.0). Based on the QUICK-DASH score, all patients showed no difficulties in daily life. The extent of avulsion did not influence the outcome.

CONCLUSION

We conclude that the minimally invasive treatment of a bony mallet finger should be offered to every patient, because it is safe, fast, and reliable. Thus, we propose to perform extension-block pinning independently of the articular area.

Palmar Shift of the Proximal Interphalangeal Joint in Different Grip Positions as a Potential Risk Factor for Periphyseal Injuries in Adolescent Climbers

INTRODUCTION

The aim of this study was to evaluate different grip positions as a contributing factor for primary periphyseal stress injuries of the finger phalanges in climbing.

METHODS

Ultrasound imaging of the proximal interphalangeal joint was performed on 37 asymptomatic adolescent climbers. Longitudinal images were obtained of middle and ring fingers of both hands in different grip positions (open, half-open, and crimp), unloaded and loaded. The translation between the dorsal head of the proximal phalanx and the shaft of the middle phalanx was measured in an unloaded and loaded situation for all grip positions. The resulting difference was determined as the palmar shift.

RESULTS

The mean age of the study population was 13 y. Results showed a palmar shift of 0.57 mm in a loaded crimp grip position compared to 0.13 mm in an open position and 0.20 mm in a half-open grip position. With a P value of <0.001, this shift was significantly higher in a crimp grip position compared to open or half-open grip positions.

CONCLUSIONS

This leads to an increase in joint incongruity and much higher peak forces on the dorsal aspect of the epiphyseal-physeal-metaphyseal complex, which is particularly vulnerable during the adolescent growth spurt. Thus, climbing and training behavior should be adapted accordingly during this phase by avoiding the crimp grip position until epiphyseal fusion.

Coverage of Palmar Mini Plates with Flexor Pulleys in the Treatment of Dorsal Fracture-Subluxation of the Proximal Interphalangeal Joint

Introduction: Dorsal fracture dislocations (DFD) of the proximal interphalangeal joint (PIPJ) are challenging fractures. A palmar surgical approach and plate fixation has a high complication rate, including flexor contractions, reduction of range of motion (ROM) and secondary need for plate removal. Methods: We use the flexor tendon pulleys to cover the mini plate with the assumption that it may reduce the adhesion between the mini plates and the tendons and reduce postoperative complications. We present the outcomes of using this technique in eight patients. Results: All patients had an excellent outcome at a mean follow-up of 17 months, and none required removal of the implants. Conclusions: This study presents a surgical technique that may potentially reduce the high complication rate found after ORIF for treatment of DFD of the PIPJ. Therefore, improving the clinical outcomes after this type of surgery. Level of Evidence: Level IV (Therapeutic).

Arthrodesis of the interphalangeal joints of the hand by two-dimensional intraosseous wiring

BACKGROUND

Numerous techniques for arthrodesis have been described to fix interphalangeal (IP) joints, and the fixation method should be considered on a case-by-case basis. This study aimed to investigate the availability of IP joint arthrodesis of the hand, using a two-dimensional intraosseous wiring (two-DIOW) method.

METHODS

A total of 43 joints (19 thumb IP joints, 9 proximal finger interphalangeal (PIP) joints and 15 distal interphalangeal (DIP) joints in 29 patients with a mean age of 66 years (range, 24-85 y) were retrospectively analyzed. All operations were performed with two-DIOW method. We evaluated the bone union rate, correction loss, presence of any surgical complications, and oral steroid use in cases of joint fixation using the two-DIOW method.

RESULTS

Of these 43 digits, 42 achieved bone union (97.7%). Non-union was seen in a thumb IP joint of mutilans rheumatoid arthritis. Mean correction loss of deviation was 1.0°, and flexion or extension angulation was 1.6° in the direction of extension. Surgical complications included mild nail deformity in 2 digits and wire irritation necessitating wire removal in 2 digits. Oral steroids were used for 18 of the 43 digits, including 2 digits complicated by nail deformities. There was no infection and skin necrosis in all digits with or without steroid use.

CONCLUSIONS

The two-DIOW method appears to offer an effective method of IP joint fixation, but caution should be exercised in digits of severe joint destruction and in the treatment of wire knot.

New body surface indexes for germinal matrix: DIP joint extension boundary line and dorsal distal interphalangeal crease

BACKGROUND

Knowledge of the proximal edge of the germinal matrix is essential to avoid injuries in the germinal matrix. The previous index such as terminal tendon insertion is not visible from the body surface. The purpose of this study was to examine the relationship between the proximal edge of the germinal matrix and the body surface indexes by ultrasonographic measurements.

METHODS

All participants underwent X-rays of the hand and were grouped based on the presence or absence of osteoarthritis in the distal interphalangeal (DIP) joint. The distance from the proximal edge of the germinal matrix to dorsal distal interphalangeal crease (parameter D1), and to ''DIP joint extension boundary line'' (parameter D2) were measured using ultrasonography.

RESULTS

Thirty middle fingers of 24 patients were enrolled; 13 fingers were in control group and 17 fingers were in Heberden's node group. The average of parameter D1 was 6.17 mm (SD 1.12) in the control group (N = 13), and was 7.04 mm (SD 1.31) in Heberden's node group (N = 17) without significant difference. The DIP joint extension boundary line was not visible in 7 fingers with severe DIP joint osteoarthritis. The average of parameter D2 was 0.00 mm (SD 0.00) in the control group (N = 13), and was 0.04 mm (SD 0.13) in Heberden's node group (N = 10).

CONCLUSIONS

We suggest that DIP joint extension boundary line and dorsal distal interphalangeal crease are valuable indexes to predict the proximal edge of the germinal matrix from the body surface. Though the DIP joint extension boundary line was not visible in some cases, once it has been sighted, the line shows where the germinal matrix exactly is.

Arthroplasty of the Proximal Interphalangeal Joint With the TACTYS Prosthesis: Clinical and Radiographic Results With a Mean Follow-up of 5 Years

BACKGROUND

Degenerative arthritis of the proximal interphalangeal (PIP) joint of the long fingers is a common disorder affecting mainly a female middle-aged population. Conservative treatment is often effective, but in some cases, pain can persist which can lead to invalidating function. Besides denervation and arthrodesis, arthroplasty is a valuable alternative treatment. The goal of this retrospective study was to determine the clinical and radiological outcomes of the TACTYS prosthesis with a mean follow-up of more than 5 years.

METHODS

Between October 2005 and August 2019 10 joints in 9 patients, one patient had two prostheses in two separate fingers (4 males and 6 women) were treated for painful degenerative arthritis of the long fingers with a TACTYS prosthesis (Stryker Inc, Kalamazoo, Michigan). Power grip and pinch force were tested preoperatively and postoperatively, and the functional outcome survey is performed using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), recall QuickDASH, and Patient-Rated Wrist Evaluation standardized questionnaires scored of 100 and the Visual Analog Scale (VAS) from 0 to 10.

RESULTS

Mean follow-up was 65.70 months (range: 23-106). Mean age was 71.5 years (range: 64-83). QuickDASH score evolved from 68.43 to 41.92, range of motion from 37.5° to 45.1°, VAS from 6.65 to 1/10. Power grip and precision pinch evolved from 16.44 to 20.80 kg and 1.97 to 2.85 kg, respectively.

CONCLUSIONS

TACTYS arthroplasty can be proposed for people who have been treated long enough with unsuccessful conservative treatment. Infection rate is still the highest complication, which can evolve in invalidating arthrodesis. It should be proposed exceptionally if the PIP joint arthritis causes invalidating functional pain.

Proximal Interphalangeal Joint Congruity: A Biomechanical Study

BACKGROUND

Surgical approaches to the proximal interphalangeal (PIP) joint often require disruption of soft tissue stabilizers. Additionally, PIP joint injuries frequently result in soft tissue disruption. This study evaluates the necessity of repairing soft tissue stabilizers by assessing their role in maintaining native joint congruity.

METHODS

Eight specimens were used to evaluate congruity at 0° and 30° flexion when loaded with 2 N of valgus force. This was performed in the native joint and after sequential sectioning of the surrounding ligaments in order: volar plate (VP), radial collateral ligament (CL), and ulnar CL. The skin flap was sutured with the ligaments unrepaired and the load was reapplied. Radiographs were taken after each load and used to measure the joint line convergence angle (JLCA).

RESULTS

Mean JLCA increased in both degrees of flexion after ligaments were sectioned but was only significantly different from the native joint after the VP was disrupted along with 1 CL. Joint congruity improved following repair of the skin flap in both degrees of flexion but was not significant. Joints were more congruent in 30° flexion for all subgroups, but none were significantly different compared to 0° flexion.

CONCLUSIONS

Disruption of the VP is insufficient to significantly alter PIP joint congruity. While sectioning of both the VP and CLs resulted in a statistically significant change in joint congruity, mean JLCA demonstrated changes of minor clinical significance. The osseous anatomy of the phalanges imparts inherent stability that maintains a congruent joint despite loss of the soft tissue stabilizers.

Closed Reduction and Percutaneous Pinning for Treatment of Proximal Interphalangeal Joint Pilon Fractures

BACKGROUND

Proximal interphalangeal (PIP) joint pilon fractures are among the challenging hand injuries, which are often associated with a wide range of complications. This study aimed to report the clinical and radiological outcomes of closed reduction and percutaneous Kirschner wire (KW) insertion with or without bone cement application (for the fabrication of an external fixator) in the treatment of PIP joint pilon fractures.

METHODS

Twenty pilon fractures underwent closed reduction and percutaneous KW fixation through a modified technique. At the end of the follow-up period, 3 questionnaires-Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH), Visual Analogue Scale for pain, and Patient-Rated Wrist Evaluation-were completed. The radiological outcome was assessed by radiography. Range of motion, and grip and pinch strength were measured.

RESULTS

The mean follow-up period was 14.57 ± 4.03 months (range, 12-20 months). The mean range of motion of PIP at the end of the follow-up period was 89.64° ± 10.82° (range, 65°-100°). The mean difference in the range of motion in the contralateral side was 21.4° ± 13°. The mean of the Quick DASH score was 13.50 ± 2.92 (range, 11-21). Two patients had residual articular malalignment, and 3 patients had angular or rotational malunion.

CONCLUSION

By treating pilon fractures with the proposed technique, we achieved a satisfactory outcome. The acceptable articular and axial alignment was achieved in 75% of patients, and complications were low. The flexibility of percutaneous KW insertion and handmade external fixators makes these approaches convenient for treating PIP joint pilon fractures.

Common Finger Fractures and Dislocations

Finger fractures and dislocations are commonly seen in the primary care setting. Patients typically present with a deformity, swelling, and bruising with loss of function. Anteroposterior, lateral, and oblique radiography should be performed to identify fractures and distinguish uncomplicated injuries from those requiring referral. Uncomplicated distal phalanx fractures, caused by a crush injury to the end of the finger, require splinting of the distal interphalangeal joint for four to six weeks. Uncomplicated dorsal avulsion fractures (mallet finger) of the distal interphalangeal joint, caused by forced flexion against resistance, require strict splint immobilization for eight weeks. Flexor digitorum profundus fractures are caused by forceful extension of the distal interphalangeal joint when in a flexed position, resulting in an avulsion fracture at the volar base of the distal phalanx, and usually require surgery. Uncomplicated middle and proximal phalanx fractures, typically caused by a direct blow, can be treated with buddy splinting if there is minimal angulation (less than 10 degrees); however, larger angulations, displacement, and malrotation often require reduction or surgery. Dorsal proximal interphalangeal joint dislocations require reduction and buddy splinting in slight flexion with an extension-block splint. Volar proximal interphalangeal joint dislocations require reduction and splinting in full extension for four to six weeks. Distal interphalangeal joint dislocations require reduction and splinting in full extension (for volar dislocations) or 15 to 30 degrees of flexion (for dorsal dislocations) for two to three weeks. Dorsal metacarpophalangeal joint dislocations are managed with reduction and splitting, but referral to an orthopedic specialist is required if the dislocation is not easily reduced. Volar metacarpophalangeal dislocations are rare and warrant referral.

Silicone Implant Arthroplasty for Severe Bony Ankylosis of the Proximal Interphalangeal Joints in Rheumatoid Arthritis

Arthrodesis and prosthetic arthroplasty have been used to treat severe proximal interphalangeal (PIP) joint arthritis. Silicone implant arthroplasty is an established treatment for rheumatoid arthritis (RA) of the fingers. However, few studies have reported the application of silicone implant arthroplasty for the treatment of severe ankylosis of the PIP joint in RA patients. The authors report, for the first time, the case of a 46-year-old woman who presented with severe bony ankylosis of the right fourth and fifth PIP joints at greater than 90° of flexion. Proximal interphalangeal silicone arthroplasty in combination with reconstruction of the extensor mechanism was successfully performed in the affected joints. Four years after surgery, active flexion of the fourth and fifth PIP joints was 55° and 75°, respectively, with an extensor lag of only 5° without pain and joint instability. Proper repair of the extensor mechanism with shortening of the central slips and mobilization of the lateral bands dorsally was most important in maintaining the extended position of the PIP joints. Proximal interphalangeal silicone arthroplasty with intensive reconstruction of the extensor mechanism could become a potential treatment option to maintain joint mobility even in severe ankylosis of the PIP joints in RA patients. [Orthopedics. 2022;45(1):e53-e56.].

Two-Year Changes in Magnetic Resonance Imaging Features and Pain in Thumb Base Osteoarthritis

OBJECTIVE

To investigate the two-year course of pain and osteoarthritic features on magnetic resonance imaging (MRI) in the thumb base.

METHODS

Patients in the Hand Osteoarthritis in Secondary Care (HOSTAS) cohort who had received radiographic examination, MRI, and clinical examination of the right thumb base at baseline and who had a 2-year follow-up period were studied. Pain on palpation of the thumb base was assessed on a 0-3 scale. MRIs were analyzed with the Outcome Measures in Rheumatology (OMERACT) thumb base osteoarthritis MRI scoring system for synovitis, bone marrow lesions (BMLs), subchondral bone defects, cartilage space loss, osteophytes, and subluxation. Radiographs were assessed for osteophytes and joint space narrowing. We studied the associations of changes in synovitis and BMLs with changes in pain using a logistic regression model adjusted for radiographic damage, with values expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Of 165 patients, 83% were women and the mean age was 60.7 years. At baseline, 65 patients had thumb base pain. At 2-year follow-up, pain had decreased in 32 patients and increased in 33 patients. MRI features remained stable in most patients. Structural MRI features generally deteriorated, while synovitis and BMLs improved in some individuals and deteriorated in others. Change in radiographic osteophytes rarely occurred (n = 10). Increased synovitis (odds ratio [OR] 3.4 [95% CI 1.3-9.3]) and increased BMLs (OR 5.1 [95% CI 2.1-12.6]) were associated with increased pain. Decreased BMLs appeared to be associated with decreased pain (OR 2.7 [95% CI 0.8-8.9]), and reductions in synovitis occurred too infrequently to calculate associations.

CONCLUSION

Over 2 years, thumb base pain fluctuated, while MRI features changed in a minority of patients with hand osteoarthritis. Changes in synovitis and BMLs were associated with changes in pain on palpation, even after adjustment for radiographic damage.

[Long fingers proximal interphalangeal joint trauma]

Sprains and dislocations of the proximal interphalangeal joint (PIP) are very common but are, nevertheless, often missed. They require an appropriate treatment to prevent stiffness and deformities. Initial assessment should include anteroposterior and true lateral radiographs. Intra-articular fractures are referred to the specialist. Clinical examination to detect laxity is essential and will guide the treatment. The treatment is based on the restoration of joint congruency and achieving early mobilization. Surgical indication is rare. The evolution is slow, pain and joint swelling can persist up to one year and definitive complications are not excluded.

Palpation of the lateral bands of the extensor apparatus of the fingers. Anatomy of a neglected clinical finding

This study aimed to determine by ultrasonography, and cadaveric dissection, whether the firm cords felt by palpation at the sides of the proximal phalanx (PP), actively flexing, and extending the proximal interphalangeal (PIP) joint while keeping the metacarpophalangeal (MCP) joint extended are the lateral bands (LBs) of the extensor apparatus. If so, palpation of the LBs could help evaluate hand conditions that impact the digits' intrinsic muscles. To this end, the PP of the middle and ring fingers of the dominant hand of seven subjects were studied by palpation on both sides. Ultrasonography (US) was performed with a hockey-stick transducer placed on the ulnar side. Five cadaveric hands were dissected, exposing the dorsal extensor apparatus. On palpation, a firm cord was consistently felt at the PP's sides in all subjects. These cords moved widely forward on PIP flexion and backward with PIP extension. By US scanning, the cords corresponded to the LBs. However, the forward movement had only a median of 1.8 mm (range 0.7-3 mm) in the middle finger and a median of 1.1 mm (range 0.3-2.7 mm) in the ring finger compared with an estimated 5-10 mm upon palpation. Cadaveric dissection confirmed the forward movement of the LBs in PIP flexion. We concluded that the firm cords felt at the PP sides are the LBs of the extensor apparatus. We confirmed their movement with the active flexion/extension of the PIP joint. Comparing the wide palpatory and the meager US motion, a haptic illusion of motion may be present.

Is a Right Angle the Right Angle? Normal Coronal Radiographic Alignment in the Pediatric Finger Phalanges

BACKGROUND

Quantifying pediatric phalanx fracture displacement requires understanding the normal radiographic alignment of pediatric phalanges, which has never been assessed in the coronal plane, although prior studies have assumed the articular surfaces and physes to be perpendicular to the diaphyses. This study tests the hypothesis that these relationships are not uniformly perpendicular and instead vary by digit and age.

METHODS

Normal hand bone age radiographs were retrospectively reviewed from 40 males and 40 females 2 to 18 years old. For each finger proximal phalanx (P1) and middle phalanx (P2), 2 raters each measured twice the angle between the diaphysis and distal articular surface (D-DA), diaphysis and physis (D-P, when physis present), and diaphysis and proximal articular surface (D-PA). Intra-rater and inter-rater reliability were calculated with intraclass correlation coefficients. 95% confidence intervals were calculated for each angle for each digit, phalanx, age group, and sex to determine which angles ~90 degrees. Variability among ages and sex was assessed with analysis of variance.

RESULTS

Intra-rater and inter-rater intraclass correlation coefficients were >0.90, except in P2 ∠D-DA in children under 8 years old with unossified P2 condyles. Overall, only 173 (47.8%) of 362 confidence intervals included 90 degrees. Three angles of the small finger (P1 ∠D-DA, P2 ∠D-P, P2 ∠D-PA) never ~90 degrees at any age or sex, with an average 10 degrees ulnar tilt of the small finger proximal interphalangeal joint. Of the 24 angles across digits and phalanges, 10 varied significantly with age, especially in the index and middle finger P1 where initially wedge-shaped epiphyses progressively became more symmetric with age.

CONCLUSIONS

The coronal radiographic angles between the phalangeal diaphyses and articular surfaces or physes differ from 90 degrees more than half the time in pediatric fingers, and nearly half the angles vary by age. These findings demonstrate that the articular surfaces and physes of the pediatric finger phalanges are not uniformly perpendicular to the diaphyses, underscoring the need to consider the variability among digits, phalanges, ages and subjects.

LEVEL OF EVIDENCE

Level IV.

Ultrasound findings of finger, wrist and knee joints in Mucopolysaccharidosis Type I

INTRODUCTION

Musculoskeletal findings in MPS can progress after enzyme replacement. Our aim was to examine synovial recesses, tendons, retinacula and pulleys using ultrasonography for structural and inflammatory changes.

MATERIAL AND METHODS

The wrist, metacarpophalangeal (MCP), proximal and distal interphalangeal (PIP and DIP) joints, the finger flexor tendons and the knee including entheses of quadriceps and patella tendons were assessed clinically. Ultrasonography of the various synovial recesses of the wrist as well as the extensor retinaculum, carpal tunnel, MCP, PIP and DIP joints of the second finger, extensor and flexor tendons, A1-5 pulleys and the knee joint including relevant entheses followed. Significance of differences between patient values and available normative data were assessed using t-tests.

RESULTS

Ultrasonography showed significant abnormal intraarticular material in the wrist without a clear distribution to synovial recesses and without effusions. Doppler signals were found in a perisynovial distribution and not intrasynovial as expected in in inflammatory arthritis. Findings were similar in the knee but not the fingers. Flexor and extensor tendons were also mostly normal in their structure but significant thickening of retinaculae and the flexor tendon pulleys was seen (p<0.0001 compared to normal).

CONCLUSION

MPS I patients showed intraarticular deposition of abnormal material in the wrist and knee but not in the finger joints where significant thickening of retinaculae/pulleys controlling tendon position was dominant. No ultrasound findings of inflammatory pathology were demonstrated but rather a secondary reaction to abnormal deposition and direct damage of GAG.

Frequency and risk factor analyses of bone erosion of the distal interphalangeal joint in patients with rheumatoid arthritis: a cross-sectional study

AIMS

Few reports have focused on the distal interphalangeal (DIP) joint in patients with rheumatoid arthritis (RA). The purposes of this study were to evaluate the frequency of bone erosion of the DIP joint, and to determine the factors associated with its deformity.

METHODS

This study reviewed 204 patients with RA in whom radiographs of hands were obtained. According to the presence/absence of bone erosion of the DIP joint, patients were divided into two groups (DIP-positive and DIP-negative groups). Additionally, wrist, metacarpal phalangeal (MP), thumb interphalangeal (IP), and proximal interphalangeal (PIP) joints were evaluated. Clinical variables such as age, sex, body mass index, disease duration, disease activity (DAS28-CRP), and drug use were investigated.

RESULTS

Regarding the radiological findings of the DIP joint, 32 patients (15.7%) were allocated to the DIP-positive group and 172 patients (84.3%) to the DIP-negative group. The mean age, disease duration, DAS28-CRP, and the rate of corticosteroids usage were significantly higher in the DIP-positive than in the DIP-negative group (p = 0.0031, 0.0062, 0.0342, and 0.0011, respectively). Radiologically, concomitant bone erosions of the wrist, MP, thumb IP, and PIP joints were significantly more common in the DIP-positive than in the DIP-negative group (p < 0.01 for all four joints). Multivariate analysis demonstrated that advanced age, long disease duration, and the presence of radiological bone erosion of the PIP joint were independently associated with bone erosion of the DIP joint (p = 0.0480, 0.0307, and 0.0021, respectively). Accordingly, in patients with DIP erosions, mean DAS28-CRP was significantly higher in patients with <5 years (n = 10) than in those with ≥5 years of disease duration (n = 22, p = 0.0088).

CONCLUSIONS

Bone erosion can be observed at the DIP joint in patients with RA, and these cases frequently shows bone erosions of other finger joints, such as PIP joint. In addition, bone erosion can be observed soon after the onset of RA caused by uncontrolled disease activity in some patients with RA.

The presence of effusions between the volar plate of the proximal interphalangeal joint and the flexor digitorum tendon is a common phenomenon: a single-center, cross sectional study

AIM

In clinical practice, an anechoic signal was often exhibited between the volar plate (VP) of the proximal interphalan-geal joint (PIPJ) (PIPJVP) and the flexor digitorum tendon (FDT) on ultrasound, which suggests the presence of effusions (PIPJVP-FDT effusions). The purpose of this study was to investigate the prevalence of PIPJVP-FDT effusions and to explore the possible mechanism preliminarily.

MATERIAL AND METHODS

A single-center, cross sectional study in hand osteoarthritis (HOA) patients, rheumatoid arthritis (RA) patients and healthy controls was conducted. Ultrasound examination was per-formed by the same real-time scanner with 18-MHz linear array transducer. Bilateral interphalangeal joints (IPJs) of the thumb, 2ed, 3rd, 4th and 5th PIPJs were examined. The PIPJVP-FDT effusions was defined as an anechoic signal between the PIPJVP and FDT in two perpendicular ultrasound planes.

RESULTS

In total, 200 patients with HOA, 78 patients with RA and 101 healthy controls were eligible for the study. 37.6% of healthy controls and 35.0% of HOA patients showed PIPJVP-FDT effusions, while only 11.5% of RA patients had PIPJVP-FDT effusions (p<0.001). The 2ed, 3rdand 4th PIPJs showed more PIPJVP-FDT effusions, while the IPJs of the thumbs and 5th PIPJs showed less PIPJVP-FDT effusions (p<0.05). Furthermore, the prevalence of PIPJVP-FDT effusions in different age groups were similar in HOA patients and healthy controls.

CONCLUSION

To the best of our knowledge, this paper is the first to demonstrate that the presence of PIPJVP-FDT effusions is a very common phenomenon in HOA patients and healthy individuals, and may be unrelated to inflammation, degeneration and age.

Familial Clustering of Erosive Hand Osteoarthritis in a Large Statewide Cohort

OBJECTIVE

Erosive hand osteoarthritis (OA) is a severe and rapidly progressing subset of hand OA. Its etiology remains largely unknown, which has hindered development of successful treatments. This study was undertaken to test the hypothesis that erosive hand OA demonstrates familial clustering in a large statewide population linked to genealogical records, and to determine the association of potential risk factors with erosive hand OA.

METHODS

Patients diagnosed as having erosive hand OA were identified by searching 4,741,840 unique medical records from a comprehensive statewide database, the Utah Population Database (UPDB). Affected individuals were mapped to pedigrees to identify high-risk families with excess clustering of erosive hand OA as defined by a familial standardized incidence ratio (FSIR) of ≥2.0. The magnitude of familial risk of erosive hand OA in related individuals was calculated using Cox regression models. Association of potential erosive hand OA risk factors was analyzed using multivariate conditional logistic regression and logistic regression models.

RESULTS

We identified 703 affected individuals linked to 240 unrelated high-risk pedigrees with excess clustering of erosive hand OA (FSIR ≥2.0, P < 0.05). The relative risk of developing erosive hand OA was significantly elevated in first-degree relatives (P < 0.001). There were significant associations between a diagnosis of erosive hand OA and age, sex, diabetes, and obesity (all P < 0.05).

CONCLUSION

Familial clustering of erosive hand OA observed in a statewide database indicates a potential genetic contribution to the etiology of the disease. Age, sex, diabetes, and obesity are risk factors for erosive hand OA. Identification of causal gene variants in these high-risk families may provide insight into the genes and pathways that contribute to erosive hand OA onset and progression.

[Extensor tendon injuries at the level of the proximal interphalangeal joint]

Closed and open injuries of the extensor mechanism at the proximal interphalangeal (PIP) joint can involve the central slip, the lateral slips or both. They are classified as zone III injuries. All open injuries on the dorsal side of the PIP joint should raise suspicion of an extensor tendon injury that is frequently overlooked. The operative strategy consists of wound revision with extensor tendon suture or refixation of the central slip. Acute closed central slip injuries are clinically diagnosed (Elson test) after ruling out bony injuries to the joint. Nondisplaced avulsions of the central slip insertion or lacerations can be treated nonoperatively by splinting. For displaced avulsions and complex injuries the treatment is surgical. In overlooked injuries a typical deformity (buttonhole/Boutonnière deformity) develops within 1-2 weeks that is characterized by an extension lag of the PIP joint and hyperextension at the distal interphalangeal joint. In early cases, when passive extension is still complete (mobile buttonhole deformity) the central slip can be immediately reconstructed. In fixed deformities complete passive extension of the PIP joint has to be restored before surgery by hand therapeutic measures or PIP joint release. Depending on the pattern of the injury and the resulting defects, a number of reconstructive techniques have been established that are summarized in this article. The functional results can be limited by tendon adhesions, imbalance within the reconstructed extensor apparatus and stiff joints that can all restrict the range of motion. Therefore, active rehabilitation protocols are mandatory for optimal results.

Topographical analysis of structural lesions between dominant and non-dominant hands in erosive osteoarthritis

KEY MESSAGES

No difference between both hands was observed for clinical and radiographical presentations in EHOA patients. A bilateral and symmetrical relationship was found between hand joints.

HIGHLIGHTS

EHOA have symmetrical distribution and specific association in structural lesions. This study aims to analyse the preferential topographical distribution of clinical and structural lesions between the dominant and non-dominant hands in erosive hand osteoarthritis (EHOA) patients. Both hands were assessed via radiography in EHOA patients. A comparative analysis of the clinical features and structural lesions between the dominant and non-dominant hands was performed. The structural lesions were assessed according to the anatomical radiographic score of Verbruggen-Veys (VV). Next, a principal component analysis was performed to describe and highlight the relationships observed between the joints. Sixty patients were included in this study: there were 57 women, and the mean age was 66.1 (± 7.6) years. For the distal interphalangeal (DIP) joints, nodes were observed more frequently on the dominant hand (4 vs 3; p = 0.005). No difference in structural lesions was observed between the two hands except for the 2nd proximal interphalangeal (PIP) (p = 0.045). A principal component analysis with varimax rotation described relationships between the 2nd PIP, 3rd PIP, 4th PIP, 4th DIP and 5th DIP joints in both hands. No significant differences between dominant and non-dominant hands were observed for clinical and structural lesions in our sample of EHOA patients. A bilateral and symmetrical injury was observed in most EHOA joints. Trial registration Clinical trial registration number: NCT01068405.

Cerclage Wire Fixation for Fracture-Dislocations of the Proximal Interphalangeal Joint

Proximal interphalangeal (PIP) joint fracture dislocations are challenging injuries to treat. Multiple and varied treatments have been proposed. We present the use of cerclage wiring as a helpful technique in these challenging scenarios. The technique has the benefit of securing fracture fragments from the volar or dorsal base of middle phalanges or a comminuted fracture involving the entire articular surface. We report on the use of cerclage wires in eight patients (average: 43 years of age). Three patients had volar base fractures, three dorsal base fractures, and two impacted fractures involving the entire articular surface. All fractures healed, and average postoperative PIP active flexion motion arc was 21° to 95° (functional arc of 74°). We believe cerclage wire fixation is an effective and reproducible method to treat intra-articular fractures of middle phalanges, especially comminuted fractures involving the entire articular surface, and should be available to hand surgeons treating these difficult injuries.

Simplified Kirschner‑wire-based dynamic external fixator for unstable proximal interphalangeal joint fractures

PURPOSE

Ligamentotaxis is a well-established treatment modality for treating challenging articular fractures. Many devices have been evolved to apply this principle to complex proximal interphalangeal joint (PIPJ) fractures. Although they gave satisfactory results, these devices were sometimes costly, complex and cumbersome. The aim of this study was to evaluate the short-term functional and radiological outcomes of treating complex intra-articular PIPJ fractures using a simplified, preloaded Kirschner‑wire (K‑wire)-based dynamic external fixator.

METHODS

Twenty consecutive patients with intraarticular PIPJ fractures, who fulfilled the study selection criteria, have been treated during 2018 and included in this prospective study after the approval of the responsible institutional ethics committee. Plain radiographs were used for assessing fracture reduction, congruity and healing. The visual analogue sore (VAS) and the Michigan Hand Outcome Questionnaire (MHQ) were used for functional evaluation. PIPJ range of motion (ROM) and hand grip-strength were also assessed.

RESULTS

At the final follow-up, all patients had no residual pain. The average PIPJ-ROM was 76.4 ± 23.51°, and the average grip-strength was 85 ± 13.95% as compared to the healthy side. The mean normalized MHQ score was 83 ± 12.63 points, with 4, 13, and 3 patients had excellent, good, and fair results retrospectively. Complications included pin tract infection (one case), stress fracture related to the applied wires (one case), and flexion contractures (four cases; three of them were symptomatic).

CONCLUSIONS

The used fixator technique is simple, reliable, available, reproducible, time-saving and cost-effective for managing complex PIPJ fractures while allowing early joint mobilization, which proven effective in achieving high satisfactory functional results.

Associations Between Radiographic and Ultrasound-Detected Features in Hand Osteoarthritis and Local Pressure Pain Thresholds

OBJECTIVE

Pain sensitization contributes to the complex osteoarthritis (OA) pain experience. The relationship between imaging features of hand OA and clinically assessed pain sensitization is largely unexplored. This study was undertaken to examine the association of structural and inflammatory features of hand OA with local pressure pain thresholds (PPTs) in the Nor-Hand study.

METHODS

The cross-sectional relationship of severity of structural radiographic features of hand OA (measured according to the Kellgren/Lawrence scale [grade 0-4] and the absence or presence of erosive joint disease) as well as ultrasound-detected hand joint inflammation (assessed by gray-scale synovitis [grade 0-3] and the absence or presence of power Doppler activity) to the PPTs of 2 finger joints was examined by multilevel regression analyses adjusted for age, sex, and body mass index, using beta values with 95% confidence intervals (95% CIs).

RESULTS

A total of 570 joints in 285 participants included in the Nor-Hand study were assessed. Greater structural and inflammatory severity was associated with lower PPTs, with adjusted beta values of -0.5 (95% CI -0.6, -0.4) per Kellgren/Lawrence grade increase, -1.4 (95% CI -1.8, -0.9) for erosive versus non-erosive joints, -0.7 (95% CI -0.9, -0.6) per gray-scale synovitis grade increase, and -1.5 (95% CI -1.8, -1.1) for joints with power Doppler activity on ultrasound versus those without.

CONCLUSION

Greater severity of structural pathologic features and hand joint inflammation was associated with lower PPTs in the finger joints of patients with hand OA, indicating pain sensitization. Our results indicate that pain sensitization might be driven by structural and inflammatory pathology in hand OA.

Incidence and progression of hand osteoarthritis in a large community-based cohort: the Johnston County Osteoarthritis Project

OBJECTIVE

To describe the incidence and progression of radiographic and symptomatic hand osteoarthritis (rHOA and sxHOA) in a large community-based cohort.

DESIGN

Data were from the Johnston County OA Project (1999-2015, 12 ± 1.2 years follow-up, age 45+). Participants had bilateral hand radiographs each visit, read for Kellgren-Lawrence grade (KLG) at 30 joints. We defined rHOA as KLG ≥2 in ≥1 joint. SxHOA was defined in a hand/joint with rHOA and self-reported symptoms or tenderness on exam. Incidence was assessed in those without, while progression was assessed in those with, baseline rHOA. Proportions or medians are reported; differences by sex and race were assessed using models appropriate for dichotomous or continuous definitions, additionally adjusted for age, education, body mass index (BMI), and weight change.

RESULTS

Of 800 participants (68% women, 32% African American, mean age 60 years), 327 had baseline rHOA and were older, more often white and female, than those without rHOA (n = 473). The incidence of HOA was high, for rHOA (60%) and for sxHOA (13%). Women were more likely than men to have incident HOA, particularly for distal interphalangeal joint radiographic osteoarthritis (DIP rOA) (adjusted odds ratios (aOR) 1.60 95% confidence intervals (95% CI) [1.03, 2.49]) and sxHOA (aOR 2.98 [1.50, 5.91]). Progressive HOA was more similar by sex, although thumb base rOA progressed more frequently in women than in men (aOR 2.56 [1.44, 4.55]). Particularly HOA incidence, but also progression, was more frequent among whites compared with African Americans.

CONCLUSION

This study provides much needed information about the natural history of HOA, a common and frequently debilitating condition, in the general population.

Impaired bone microarchitecture in distal interphalangeal joints in patients with primary hypertrophic osteoarthropathy assessed by high-resolution peripheral quantitative computed tomography

This study aimed to investigate the bone impairment in finger joints in PHO patients by HR-pQCT. Results showed distinguished differences in bone architecture and biomechanics parameters at DIPs between PHO patients and healthy controls using HR-pQCT assessment. Besides, serum PGE2, hsCRP and ESR levels were found negatively correlated with total vBMD.

INTRODUCTION

This study aimed to investigate the bone impairment in finger joints in primary hypertrophic osteoarthropathy (PHO) patients firstly by high-resolution peripheral quantitative computed tomography (HR-pQCT).

METHODS

Fifteen PHO patients and 15 healthy controls were enrolled in this study. Bone erosions in hands at distal interphalangeal joints (DIPs) in both PHO patients and controls were evaluated by X-ray. Bone geometry, vBMD, microstructure parameters, and size of individual bone erosion were also measured at the 3rd DIP by HR-pQCT as well. Blood biochemistry levels between the two groups were also compared.

RESULTS

Compared to X-ray, HR-pQCT assessment were more sensitive for detection of bone erosions, with 14 PHO patients by HR-pQCT versus ten PHO patients by X-ray judged at the 3rd DIP. The average depth, width, and volume of erosions size in PHO patients were 1.38 ± 0.80 mm, 0.79 ± 0.27 mm, and 1.71 ± 0.52 mm³, respectively. The bone cross-areas including total area (+ 25.3%, p ≤ 0.05), trabecular area (+ 56.2%, p ≤ 0.05), and cortical perimeter (+ 10.7%, p ≤ 0.05) at the defined region of interest of 3rd DIP was significantly larger than controls. Total vBMD was 11.9% lower in PHO patients compared with the controls (p ≤ 0.05). Biochemical test results showed the increased levels of inflammatory cytokines, bone resorption markers, and joint degeneration markers in PHO patients. Serum prostaglandin PGE2, high-sensitive C-reactive protein (hsCRP) and erythrocyte sedimentation rate (ESR) levels were found negatively correlated with total vBMD.

CONCLUSIONS

This study demonstrated higher sensitivity of the HR-pQCT measurement at DIPs by showing the differences in architecture and biomechanics parameters at DIPs between the PHO patients and healthy controls, which would be of interest clinically to investigate bone deterioration in PHO patients.

Correlation between Hypervascularization of the First Annular Pulley on Color Doppler Imaging of Trigger Finger and Patients' Backgrounds

OBJECTIVES

The aim of this study was to investigate the correlation between hypervascularization of the first annular (A1) pulley on color Doppler imaging of trigger finger and patients' backgrounds.

METHODS

A total of 148 trigger digits from 144 patients were studied with ultrasound at the time of initial diagnosis. We observed the A1 pulley at the level of the metacarpophalangeal joint in a transverse image and noted the presence or absence of a signal in the A1 pulley on color Doppler imaging. Patients' ages, sexes, clinical grades, symptom durations, prevalence of interphalangeal joint contracture, and visual analog scale pain scores were compared between the groups with positive and negative Doppler findings.

RESULTS

The 144 patients included 45 men and 99 women. Sixty-one of 148 digits (41%) showed positive Doppler findings in the A1 pulley. Patients' ages and visual analog scale scores in the Doppler-positive group were slightly greater than those in the Doppler-negative group (P = .03; P < .01, respectively). The digit with positive Doppler findings tended to be categorized into a severer grade and into the group with a shorter symptom duration (P < .01 for both).

CONCLUSIONS

Hypervascularization of the A1 pulley tended to appear in an earlier period after the patients had become aware of symptoms, as frequently as their symptoms became severe, in conjunction with higher pain scores. Doppler imaging of the A1 pulley might help in better understanding patients' conditions.

A Rare Case of Chromoblastomycosis in a 12-year-old boy

Chromoblastomycosis is a chronic fungal infection of the subcutaneous tissue. The infection usually results from a traumatic injury and inoculation of the microorganism by a specific group of dematiaceous fungi, resulting in the formation of verrucous plaques. The fungi produce sclerotic or medlar bodies (also called muriform bodies or sclerotic cells) seen on direct microscopic examination of skin smears. The disease is often found in adults due to trauma. We report a case of chromoblastomycosis in a 12-year-old child in whom the infection started when he was only 4 years old with secondary involvement of bones, cartilage, tongue and palatine tonsils. The child was not immunosuppressed.

Enthesitis and Dactylitis in Psoriatic Disease: A Guide for Dermatologists

Psoriatic arthritis (PsA) is an inflammatory arthritis that is estimated to affect approximately 30% of patients with psoriasis. Enthesitis and dactylitis, two hallmarks of PsA, are associated with radiographic peripheral/axial joint damage and severe disease. Clinical symptoms of enthesitis include tenderness, soreness, and pain at entheses on palpation, whereas dactylitis is recognized by swelling of an entire digit that is different from adjacent digits. Both ultrasound and magnetic resonance imaging can be used to diagnose enthesitis and dactylitis, especially in patients in whom symptoms may be difficult to discern. Delayed treatment of PsA can result in irreversible joint damage and reduced quality of life. Thus, it is recommended that dermatologists monitor patients with psoriasis for these two early and important manifestations of PsA.

Thermoacoustic Tomography of In Vivo Human Finger Joints

OBJECTIVE

the purpose of this study was to demonstrate the potential of thermoacoustic tomography (TAT) to reveal anatomic structures of in vivo human finger joints.

METHODS

all the participating volunteers provided written informed consent. Eight healthy middle and index fingers from five volunteers were imaged in vivo by our TAT imaging system. Axial T1-weighted MR imaging (3.0 T) was used to validate the TAT findings. Comparative analyses between TAT and MRI images were performed in two dimension for all the fingers imaged. Three-dimensional (3-D) images and animations were also obtained for some of the fingers thermoacoustically scanned.

RESULTS

various intra- and extra-articular tissues were identified in TAT images in high fidelity. These TAT images matched well with the MRI images. Both the 3-D images and animations effectively displayed the extension and transformation of the entire finger along the axis.

CONCLUSION

TAT can noninvasively visualize anatomic structures of the finger joints based on the electrical properties of the joint tissues. The results obtained indicate that TAT may have the potential to contribute to the detection of joint and bone diseases.

SIGNIFICANCE

this study represents the first for TAT of in vivo human joints and fingers. This study reveals that TAT can effectively recover both soft and hard tissues of the healthy interphalangeal joints, which provides a foundation for its clinical application to detection and diagnosis of joint and bone diseases.

[Phalangeal fractures of the hand]

Phalangeal fractures are common in all ages. Stable, extra-articular fractures can be treated non-operatively by closed reduction and buddy taping, while surgical fixation should be considered for unstable and displaced extra-articular fractures and most intra-articular fractures. The treatment should aim at early, active mobilisation in order to achieve the optimal functional outcome. Since intra-articular frac-tures, proximal interphalangeal joint fracture dislocations, open fractures and certain paediatric fractures can lead to poor functional outcome, referral to a hand surgeon is recommended.

Development of a scoring method to visually score cortical interruptions on high-resolution peripheral quantitative computed tomography in rheumatoid arthritis and healthy controls

Objectives

To develop a scoring method to visually score cortical interruptions in finger joints on High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT), determine its intra- and inter-reader reliability and test its feasibility.

Methods

The scoring method was developed by integrating results from in-depth discussions with experts, consensus meetings, multiple reading experiments and the literature. Cortical interruptions were scored by two independent readers in an imaging dataset with finger joints from patients with rheumatoid arthritis (RA) and healthy controls and assessed for adjacent trabecular distortion. Reliability for the total number of cortical interruptions per joint and per quadrant was calculated using intraclass correlation coefficient (ICC). Feasibility was tested by recording the time to analyze one joint.

Results

In 98 joints we identified 252 cortical interruptions, 17% had trabecular distortion. Mean diameter of the interruptions was significantly larger in patients with RA compared with healthy controls (0.88 vs 0.47 mm, p = 0.03). Intra-reader reliability was ICC 0.88 (95% CI 0.83;0.92) per joint and ICC 0.69 (95% CI 0.65;0.73) per quadrant. Inter-reader reliability was ICC 0.48 (95% CI 0.20;0.67) per joint and ICC 0.56 (95% CI 0.49;0.62) per quadrant. The time to score one joint was mean 9.2 (SD 4.9) min.

Conclusions

This scoring method allows detection of small cortical interruptions on HR-pQCT imaging of finger joints, which is promising for use in clinical studies.

Swan neck deformity due to chronic radial collateral ligament injury of the little finger proximal interphalangeal joint

We present seven cases of a relatively rare swan neck deformity resulting from chronic radial collateral ligament (RCL) injury of the proximal interphalangeal (PIP) joint in the little finger. All patients were middle-aged women (mean 51 years old, range 42-55), and the duration between the initial injury and surgery was 20 years (range 5-40). The chief complaint was painful snapping of the PIP joint. All patients had hyperextension and ulnar deviation of the PIP joint with mobile swan neck deformities that had not improved with conservative treatment. Radiographs revealed osteoarthritis and ulnar deviation of the PIP joints in all cases. We describe a method for reconstruction of both the palmar plate and the RCL of the affected PIP joint using a distally-based ulnar slip of flexor superficialis tendon. The prevention of PIP joint hyperextension was critical for successful resolution of symptoms; the aim of RCL augmentation was to prevent the recurrence of the deformity.

LEVEL OF EVIDENCE

IV.

Management of Proximal Interphalangeal Joint Fracture Dislocations

Fracture dislocations of the proximal interphalangeal (PIP) joint of the finger are often caused by axial load applied to a flexed joint. The most common injury pattern is a dorsal fracture dislocation with a volar lip fracture of the middle phalanx. Damage to the soft-tissue stabilizers of the PIP joint contributes to the deformity seen with these fracture patterns. Unfortunately, these injuries are commonly written off and left untreated. A late-presenting PIP joint fracture dislocation has a poor chance of regaining normal range of motion. The provider must be suspicious of these injuries. Treatment options and algorithm are reviewed.

A Novel Method of Synovitis Stratification in Ultrasound Using Machine Learning Algorithms: Results From Clinical Validation of the MEDUSA Project

Ultrasound is widely used in the diagnosis and follow-up of chronic arthritis. We present an evaluation of a novel automatic ultrasound diagnostic tool based on image recognition technology. Methods used in developing the algorithm are described elsewhere. For the purpose of evaluation, we collected 140 ultrasound images of metacarpophalangeal and proximal interphalangeal joints from patients with chronic arthritis. They were classified, according to hypertrophy size, into four stages (0-3) by three independent human observers and the algorithm. An agreement ratio was calculated between all observers and the standard derived from results of human staging using κ statistics. Results was significant in all pairs, with the highest p value of 3.9 × 10^-6. κ coefficients were lower in algorithm/human pairs than between human assessors. The algorithm is effective in staging synovitis hypertrophy. It is, however, not mature enough to use in a daily practice because of limited accuracy and lack of color Doppler recognition. These limitations will be addressed in the future.

Xanthomatosis in bilateral hands mimicking rheumatoid arthritis: A case report

RATIONALE

Xanthomatosis often accompanies familial hypercholesterolemia. This disease usually occurs in tendons, most commonly located in the Achilles tendon; occasionally it can also be seen in other systems. Although there are previous reports for bilateral hand extensor tendon involvement, to our knowledge there is no report in English literature regarding bilateral hands with small joint synovium presenting as rheumatoid arthritis. Therefore, the case that is presented in this report is unique.

PATIENT CONCERNS

An 18-year-old woman was admitted to our department because she presented with morning stiffness, joint deformation, and swelling in both hands. Computed tomography of the right hand showed soft tissue swelling on multiple small joints, including metacarpophalangeal and proximal interphalangeal joints, but without obvious bone destruction. There was soft tissue swelling around the small joints, which were hypointensities on T1-weighted and hyperintensities on T2-weighted images, not uniformly enhanced appearances on magnetic resonance imaging.

DIAGNOSES

Biopsy from the 3rd metacarpophalangeal joint capsule of the left hand confirmed xanthoma.

INTERVENTIONS

She was treated with statin drugs to reduce blood fat.

OUTCOMES

After 3 months of follow-up, no recurrence or complications were detected regarding a full range of motion remaining of the affected joints.

LESSONS

The young patient with symptoms of small joint synovium involved in both hands and the performance of magnetic resonance imaging similar to rheumatoid arthritis may be suffering from xanthomatosis.

Could nail and joint alterations make the difference between psoriatic arthritis and osteoarthritis during the ultrasonographic evaluation of the distal interphalangeal joints?

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The Reliability of a Semi-automated Algorithm for Detection of Cortical Interruptions in Finger Joints on High Resolution CT Compared to MicroCT

We developed a semi-automated algorithm for the detection of cortical interruptions in finger joints using high-resolution peripheral quantitative computed tomography (HR-pQCT). Here, we tested its reliability compared to microCT (µCT) as gold standard. Nineteen joints of 10 female anatomic index fingers were imaged by HR-pQCT and µCT (82 and 18 µm isotropic voxel sizes, respectively). The algorithm was applied for detection of cortical interruptions of different minimum diameters (range >0.16 to >0.50 mm). Reliability was tested at the joint level with intra-class correlation coefficient (ICC) for the number of interruptions and interruption surface, and at the level of a single interruption for matching between HR-pQCT and µCT with a fixed interruption diameter (>0.10 mm) on µCT. The positive predictive value (PPV_0.10mm) and sensitivity_0.10mm were evaluated. The mean number of interruptions per joint depended on the diameter cut-off and ranged from 3.4 to 53.5 on HR-pQCT and from 1.8 to 45.1 on µCT for interruptions >0.50 to >0.16 mm, respectively. Reliability at the joint level was almost perfect (ICC ≥0.81) for both the number and surface of interruptions >0.16 and >0.33 mm. As expected, the PPV_0.10mm increased with increasing interruption diameter from 84.9 to 100%, for interruptions >0.16 and >0.50 mm, respectively. However, the sensitivity_0.10mm decreased with increasing interruption diameter from 62.4 to 4.7%. This semi-automated algorithm for HR-pQCT in finger joints performed best for the detection of cortical interruptions with a minimum diameter of >0.16 or >0.33 mm, showing almost perfect reliability at the joint level and interruptions matched with those on µCT.

Interphalangeal Joint Sonography of Symptomatic Hand Osteoarthritis: Clinical and Functional Correlation

OBJECTIVES

To assess the correlation between inflammatory sonographic findings (grayscale synovial hypertrophy and power Doppler) and clinical and functional assessments in hand osteoarthritis (symptomatic interphalangeal joints) and to correlate the intraobserver and interobserver reliability of these findings.

METHODS

A prospective double-blind study of 60 interphalangeal joints was conducted. The joints were assessed 6 times per year by clinician and sonographer observers.

RESULTS

A total of 720 measurement recesses were included (360 palmar and 360 dorsal). Small correlations and a few associations were found. Proximal interphalangeal joint quantitative measurements of the dorsal recess showed a statistical correlation with joint swelling (P = .043) and pulp-to-pulp pinch strength (P = .043); in the palmar recess, statistical correlations were seen for joint swelling (P = .007), the Australian/Canadian (AUSCAN) Function Index (P = .044), and grip and finger strength (P = .037, .003, .019, and .017). In dorsal semiquantitative assessments, there were associations between sonographic findings and joint swelling (P = .010) and pinch strength (P = .027, .003, and .014); in the palmar recess, we found associations with the AUSCAN Index (P = .048) and grip and finger strength (P = .031, .006, and 0.041). No correlations or associations were found in distal interphalangeal joints. Power Doppler signals were found in only 1.7% of the sample, precluding statistical analysis. Excluding palmar semiquantitative assessments in distal interphalangeal joints (P = .623), sonographic findings were reliable (intraclass correlation coefficients, 0.474-0.857; κ = 0.390-0.673).

CONCLUSIONS

Joint swelling, grip and pinch strength, and the AUSCAN Index were weakly correlated and associated with sonographic findings in proximal interphalangeal joints. Intraobserver and interobserver sonographic assessments were reliable.

Lessons Learned from the Management of Complex Intra-Articular Fractures at the Base of the Middle Phalanges of Fingers

The use of dynamic traction splintage is established in the treatment of complex intra-articular phalangeal fractures. Several different systems have been used and we report our experience with one of these, the Pins and Rubber Traction System. A cohort of 14 patients with complex intra-articular fractures at the base of the middle phalanges of the fingers were treated and assessed prospectively over a 2.5-year period (mean, 20 months; range, 7–28 months). The mean active range of motion regained, at the proximal interphalangeal joint, was 74° (range, 0–100°). The mean total active motion of the injured digit was 196° (range, 40–275°). Refinements in the regime are suggested as a result of this investigation.

Small Joint Fusion of the Hand – A Technique Using Coughlin Cup and Cone Reamers

We describe a method of cup and cone arthrodesis using Coughlin concave and convex reamers, which we have used in a series of 22 hand joints in 19 patients. These reamers, originally designed for use in the foot, can be used in the hand to give very accurate preparation of bone surfaces. This results in maximum bone contact and the ability to fuse the joint in any desired position. The procedure is simple, rapid and forgiving. Union was achieved in all 22 cases, usually within 3 months.

Clinical outcomes of operative repair of complete rupture of the proximal interphalangeal joint collateral ligament: Comparison with non-operative treatment

Objectives

The purpose of this study was to compare the outcomes of non-operative treatment and operative repair of grade III injuries with complete rupture of the collateral ligament of the proximal interphalangeal (PIP) joint.

Patients and methods

Seventeen patients with grade III injuries with at least 6 months of follow-up were included. Seven patients underwent non-operative treatment and 10 patients underwent operative treatment. We evaluated the following clinical outcomes after treatment: 1) range of motion of the PIP and distal interphalangeal (DIP) joints, 2) joint stability, 3) pain score, and 4) amount of fusiform deformity of the PIP joint.

Results

There was no instability in the lateral stress test in either group. The ranges of motion of the PIP and DIP joints were not statistically different between the two groups at final follow-up. However, the ranges of motion recovered more quickly in the operative group than the non-operative group within the first 3 months after treatment. Patients in the operative group had less pain and better cosmetic appearance of the PIP joint.

Conclusion

Our results suggest that operative repair of the PIP collateral ligament can provide good joint stability, rapid functional recovery, and minimize fusiform deformity of the PIP joint.

Level of evidence

Level III, Therapeutic study.

Diagnostic Accuracy of Ultrasonography in Detection of Destructive Changes in Small Joints of Hands in Patients of Rheumatoid Arthritis: A Comparison with Magnetic Resonance Imaging

BACKGROUND

Ultrasonography can be used in early Rheumatoid Arthritis to determine and to follow parameters of joint inflammation, such as effusion, synovitis, and marginal erosion that can be radiologically occult. We therefore planned a study to investigate whether Ultrasonography could provide information on signs of inflammation and destruction in Rheumatoid Arthritis affected finger joints that was not available with Radiography and compared it to the information provided by Magnetic resonance imaging.

STUDY DESIGN

Hospital Based Descriptive Study.

METHODS

The study included 30 patients fulfilling American College of Rheumatology 2010 criteria of Rheumatoid Arthritis with no erosions present on radiographs of hands. Erosion, Synovial thickening/vascularity, effusion and Tenosynovitis of Flexor tendon sheath / Extensor tendon sheath were assessed on both Ultrasonography and Magnetic resonance imaging.

STASTICAL ANALYSIS

Considering Magnetic resonance imaging as gold standard sensitivity, specificity, positive predictive value, negative predictive value and kappa value of Ultrasonography were calculated. Kappa value was calculated by kappa statistics to show agreement between the two modalities.

RESULTS

Ultrasonography and Magnetic resonance imaging had near perfect agreement for detecting synovial thickening and vascularity, substantial agreement for detecting effusion, Flexor tendon sheath / Extensor tendon sheath inflammation, and only moderate agreement for detecting erosions in Metacarpophalangeal and Proximal interphalangeal joints.

CONCLUSION

The early diagnosis of Rheumatoid Arthritis by Ultrasonography and MRI is very important to early treatment of Rheumatoid Arthritis. Ultrasonography is a reliable method for assessing inflammatory activity and destructive changes in small joints of hand as the Ultrasonographic findings are comparable to those of MRI.