Carlos Pineda

Hypothenar hammer syndrome. Form of reversible Raynaud's phenomenon

Hypothenar hammer syndrome is a reversible yet uncommonly encountered cause of Raynauds phenomenon. Characteristic findings include coldness in the dominant hand of a male, absence of triphasic color change and thumb involvement, and occupational or recreational use of the hand as a hammer. Angiography demonstrates the specific findings of irregularity or occlusion of the ulnar artery, downstream occluded proper digital arteries, and intraluminal emboli at the sites of distal obstruction. A vulnerable area of traumatic occlusion is provided by the anatomic relationship of the superficial branch of the ulnar artery to the hamate bone and the palmar aponeurosis. Pathologic studies separate the hypothenar hammer syndrome from clinically similar vasculitis. It is important to recognize the hypothenar hammer syndrome as a distinct entity because treatment is curative and consists of resection of the affected vascular segment and avoidance of the aggravating conditions.

Primary hypertrophic osteoarthropathy

We describe seven patients with primary HOA and review 125 cases reported in the English, French, and German literature. The salient clinical features of primary HOA are: a bimodal distribution of disease onset with one peak during the first year of life and the other at age 15, a male predominance (nine to one), uncommon benign joint effusion, and a variety of skin abnormalities resulting from cutaneous hypertrophy or glandular dysfunction. We concluded that HOA is not a synovial disease. It is suggested that synovial effusions, when present, are perhaps a sympathetic reaction to the neighboring periostitis. Proposed diagnostic criteria for HOA, including digital clubbing and radiographic periostitis, appear 86% sensitive. The clinical features, age of onset, and sex distribution suggest that a genetically controlled growth promoting factor, different from growth hormone, plays a role in the pathogenesis of this syndrome.

The Skeletal Manifestations of Clubbing: A Study in Patients With Cyanotic Congenital Heart Disease and Hypertrophic Osteoarthropathy

The skeletal manifestations of clubbing of the digits have been occasionally noted and only briefly discussed in the literature. We investigated the radiographic features of digital clubbing in 37 patients with diverse diseases including cyanotic congenital heart disease, lung malignancy-associated hypertrophic osteoarthropathy, and idiopathic cases. We identified two types of bone changes--osteolysis or bone dissolution, and bone formation or hypertrophy. The changes were more evident in the feet than in the hands, and the degree of soft tissue change did not always reflect the underlying osseous abnormalities. The relationship of these changes (ie, osteolysis, hypertrophy) to each other appear to depend in part on the underlying disease as well as the time course or disease duration. Thus, clubbing and hypertrophic osteoarthropathy may not represent distinct entities; our data suggest that they may be stages in an evolving, more generalized process of new bone formation or hypertrophy followed by osteolysis or atrophy affecting many parts of the skeleton.

Diagnosis of tarsal coalition with computed tomography.

The value of computed tomography in the diagnosis of tarsal coalition is reported in six patients, five with talocalcaneal coalition and one with calcaneo-navicular coalition. The examination is technically easy to perform with the patient in the supine position and the knees flexed, and it allows simultaneous visualization of both sides. Because of these features and an ability to distinguish between bony and cartilaginous or fibrous fusion, computed tomography appears to be the method of choice for diagnosis of coalition involving talus and calcaneus. It is less useful in other types of coalition.

Evidence of Hypertrophic Osteoarthropathy in Human Skeletal Remains from Pre-Hispanic Mesoamerica

Hypertrophic osteoarthropathy is a disease entity characterized by a peculiar bulbous deformity of the digits conventionally described as clubbing and by periosteal proliferation of the tubular bones. Its presence usually indicates a serious internal illness, such as cyanotic heart disease, cystic fibrosis, lung cancer, or liver cirrhosis. Nevertheless, instances occur in which the syndrome is manifested without any underlying illness; these patients are classified as having primary hypertrophic osteoarthropathy [1]. Clubbing is one of the earliest recognized abnormalities in the history of medicine; it was originally described by Hippocrates (about 450 B.C.). When roentgen rays became available as a diagnostic tool at the end of the 19th century, periostosis of the tubular bones was identified as the other key characteristic of the syndrome. Synovial effusion of the large joints is a frequent finding in such patients [1]. The periostosis of hypertrophic osteoarthropathy has peculiar aspects that allow its differentiation from other bone diseases [2, 3]. It is a progressive process that affects mainly the tubular bones, principally the tibia and fibula. It is bilateral and symmetric. There is no involvement of the medullary cavity, the axial skeleton, or the skull. In mild cases of the disease, the periosteal apposition is limited to the diaphysis and has a monolayer configuration; in advanced stages, it thickens the cortex of the bones, imprinting a tree bark configuration, and thus leaves an indelible mark [4]. Another distinctive aspect of the syndrome, which has been recently defined, is that clubbing is accompanied by remodeling changes of the underlying distal phalanges [1, 5]. These peculiar features of hypertrophic osteoarthropathy, in addition to the fact that the skeleton is the only part of the body able to withstand the passage of time, provide a unique opportunity to identify this illness in human skeletal remains. In pre-Hispanic Mesoamerica, death was considered a transition; therefore, persons were buried with different types of offerings, such as food, utensils, and figurines, to assist them in their journey. During exploration of the diverse ceremonial centers of Mesoamerica, a careful study of the burial sites with their skeletal remains and offerings was also done. These specimens are classified and preserved at the National Museum of Anthropology of Mexico City. This collection is an excellent source of information for the study of Mesoamerican osteopaleopathology. We examined human skeletal remains from pre-Hispanic Mesoamerica for evidence of hypertrophic osteoarthropathy. Methods The skeletal remains preserved at the physical anthropology department of the National Museum of Anthropology of Mexico City were studied. A total of 1000 specimens originating from diverse pre-Hispanic sites were examined for the following features: 1) adequate state of preservation; 2) bilateral symmetric periostosis of tubular bones that was evident on visual examination; 3) lack of involvement of the axial skeleton and the skull; and 4) remodeling of the distal phalanges. Those specimens that fulfilled such criteria had a radiographic survey including anteroposterior views of the tubular bones. The charts describing the findings during excavation of the burial sites were reviewed. For comparison, skeletons matched for gender, age range, chronology, and burial site were also studied. One of the specimens that had hypertrophic osteoarthropathy originated from Jaina Island. Jaina is a Mayan necropolis from the Classic period (300 to 900 A.D.) and is famous for its figurines of persons doing typical daily activities or having signs of diverse illnesses [6]. The museums collection of figurines from Jaina was studied for evidence of digital clubbing or for any of the illnesses known to be associated with hypertrophic osteoarthropathy [1]. Results Two specimens fulfilled criteria that were consistent with the diagnosis of hypertrophic osteoarthropathy. Specimen 1 The bones belonged to a young woman found in burial site 23 during the 1974 exploration of Jaina. A conspicuous thickening of the tibias and fibulas with a tree bark configuration of their cortex was evident. A lesser degree of periostosis was found in the femora, radii, and ulnae. Only one distal phalanx was preserved; it was truncated. No alteration of the axial skeleton was noted. Radiographs showed thickening of the cortex of tubular bones due to a multilayered type of periosteal apposition (Figure 1, top). No abnormalities of the medullary cavity were noted. The periosteal changes clearly differed from the condition of the skeletons used for comparison. Figure 1. Top. Middle. arrows Bottom. right left Specimen 2 The skeleton of a young man was found in burial site 17 of Ticoman in the central part of Mexico. It belonged to the Formative period (2000 B.C. to 100 A.D.). It had a widespread shaggy periostosis involving tibias, fibulas (Figure 1, middle), femora, radii, ulnae, and metatarsal bones. Two distal phalanges of the feet were preserved. Figure 1, bottom, shows the prominent remodeling changes consistent with digital clubbing, clearly different from the skeletons used for comparison. No alteration of the axial skeleton or the skull was noted. Radiographs showed widespread periosteal proliferation of the tubular bones, without involvement of the marrow. Review of the Jaina figurines did not indicate any example of digital clubbing; however, these figurines had a crude modeling of the hands. A sculpture of a man depicted massive ascites Figure 2, a gross abdominal deformity usually associated with chronic liver disease, which is a well-known cause of hypertrophic osteoarthropathy [1, 7]. Figure 2. Ancient Mesoamerican illness. Discussion The widespread, bilateral, symmetric periostosis of these specimens from two persons strongly suggests hypertrophic osteoarthropathy. Other causes of hyperostosis and periostitis can be ruled out [3]. An infectious disease, such as treponematosis, is unlikely on the basis of the diffuse symmetric involvement and the lack of concomitant destructive lesions of the underlying medullary bone. Melorheostosis is asymmetric and also involves the pelvis and the skull. Osteopoikilosis and osteopathia striata are accompanied by disseminated radio-opaque changes. Hypervitaminosis A and fluorosis also affect the axial skeleton. Chronic venous stasis is found in older persons, and the bone changes are limited to the lower extremities [3]. More unequivocal evidence for the diagnosis of hypertrophic osteoarthropathy was found in specimen 2, which also showed the bone remodeling process of the distal phalanges that is typical of clubbing [5]. The only preserved phalanx of specimen 1 had bone dissolution, an alteration also reported in clubbing [5]; it is not possible to ascertain whether this finding was due to postmortem decay. With the information gathered, we cannot define which underlying illness caused the hypertrophic osteoarthropathy in these two specimens. It has been recently determined that the shape of the periosteal apposition is not dependent on the underlying disease but rather on its duration. Moreover, primary and secondary hypertrophic osteoarthropathy may feature similar periostosis [2]. The advanced changes seen in our two specimens suggest that the persons had had the disease for a long time. Of additional interest was the Jaina figurine depicting ascites. To recognize most of the illnesses associated with hypertrophic osteoarthropathy, modern diagnostic tools are required. However, ascites is a gross abdominal deformity recognizable by visual examination. We are aware of no previous studies attempting to identify hypertrophic osteoarthropathy in ancient skeletal remains from any part of the world. A report exists of a prominent hyperostosis occurring in a left femur from the Huari civilization of Peru (about 1000 A.D.) [8]; unfortunately, the femur was the only tubular bone recovered so no further inferences could be made. Our report shows that hypertrophic osteoarthropathy can be recognized in ancient human skeletal remains and suggests that the disease was present in Mesoamerica near the time of its original description by Hippocrates.

Plantar compartmental infection in the diabetic foot. The role of computed tomography.

This review discusses the role of computed tomography (CT) in the evaluation of extent of plantar soft tissue infection in the diabetic foot. CT abnormalities are correlated with conventional radiography, results of preoperative aspiration cultures, intraoperative assessment, and bone, gallium, and 111In-leukocyte scan findings. Plantar soft tissue disease respects compartmental boundaries in general, with transcompartmental spread possible along musculotendinous units that normally transgress the intervening fascial septae. CT correlates well with the extent of infection as determined by other modalities, but cannot precisely predict its proximal boundary due to gradual transition between unequivocally abnormal and normal tissue. CT may be useful in establishing an appropriate level for contemplated amputation and can detect extension of superficial diabetic foot infections at an earlier stage than existing clinical methods, potentially resulting in less extensive surgical procedures.

Primary hypertrophic osteoarthropathy: Another heritable disorder associated with patent ductus arteriosus

SummaryPatent ductus arteriosus (PDA) is a congenital malformation that has been linked to diverse heritable and chromosomal disorders. Primary hypertrophic osteoarthropathy (HOA) is a rare heritable syndrome in which digital clubbing and periostosis become evident without any underlying illness.The objective of this article is to describe four patients with coexisting PDA and primary HOA. Surgical closure of the ductus showed no effect on the skeletal changes.Primary HOA should be included among the heritable disorders that may be associated with PDA.

Digital arthrography in the evaluation of painful joint prostheses.

Digital arthrography was accomplished in 16 patients who had painful prostheses. In each instance, resulting arthrographic abnormalities were compared with those apparent on subsequent overhead radiographs. Results indicate the potential value of the digital technique in this clinical setting. The examination is easy to perform and rapid, and allows the examiner to view the changing images in the subtraction mode. Image manipulation and enhancement are also possible.

CT analysis of proximal femoral trabecular pattern simulating skeletal pathology.

The proximal femoral trabecular pattern was studied in 20 patients, six cadavers, and 20 macerated specimens using plain film radiography and CT. A distinctive pattern of increased radiodensity in the proximal femur is described in patients and specimens with osteoporosis and osteoarthritis. The appearance is similar to that of an enchondroma or bone infarct. This pattern may be explained by biomechanical principles and is created by unmasking or hypertrophy of preexistent, reinforcing trabeculae. Confusion with osseous pathology can be avoided if the radiologist is aware of this pattern.