0000068546 00000 n Fingernail involvement presents radiographically as areas of thickening and irregularity. Toes: Anatomy, Pathology and Common Surgical Procedures 1 Emory University Hospital, Department of Radiology Section of Musculoskeletal Imaging, USA 2 Emory University Hospital, Department of Orthopedic Surgery, USA 3 University of Miami, Department of Radiology Section of Musculoskeletal Imaging, USA Adam Singer, MD1; Jason Bariteau, MD2; Yara Younan, MD 1; Walter Carpenter, MD Differentiating enchondroma from low-grade chondrosarcoma can prove more troublesome, deep endosteal scalloping affecting at least two-thirds of the lesion is thought to be the most specific sign. xref [34] It can also represent a long-term re-ossification process following acro-osteolysis. We use cookies to ensure that we give you the best experience on our website. <<4A46F1E94CB88E4CA54EF8576B9B123B>]/Prev 554180>> 7). The incidence of phalangeal fractures is the highest in children aged 10 to 14 years, wh … The body of each is compressed from side to side, convex above, concave below. As enchondromas are benign and asymptomatic, typically no follow-up is needed. 0000068812 00000 n [26] Fusiform swelling of the overlying digital soft tissue is an early finding, as to is enlargement of the nutrient foramen. Ten–30 years may elapse before there is a substantial shortening of the digital soft tissue and underlying bones. Diffuse osteosclerosis is seen typically in scleroderma, systemic lupus erythematous, and collagen vascular disorders. How to cite this article: Rajakulasingam R, Azzopardi C, Murphy J, Davies M, Toms A, James S, et al. [13] The glomus body can hypertrophy appearing as a pale pink or purple mass under the nail bed. capitate. 8A,B). 0000011948 00000 n The main differential for phalangeal sarcoidosis is gout. These phalanges are the bones of the toes (37). The phalanges are located distally from the metatarsal bones (36). Bony loss is very slow; hence, radiographic changes are often only seen in longstanding cases. It is the most common lesion in the phalanges, i.e. Lesions involving short tubular bones of the hand generally parallel those in long bones. 0000004745 00000 n Patient's consent not required as patients identity is not disclosed or compromised. Even though most lesions are benign, it is crucial to differentiate them as some may be the first presentation of more a systemic condition. 0000011921 00000 n Joe Hug. [22] Increased uptake can be delayed even up to a few days from the onset of infection in nuclear medicine studies. Contributed by … 106 0 obj <> endobj The base is concave; and the head presents a trochlear surface for articulation with the second phalanx. There is unrelated flattening and sclerosis of the second and third metatarsal heads due to healed avascular necrosis (AVN). [27] Chronic cases with the established disease over many decades radiographically tend to resemble a severely deforming polyarthritis. When in the phalanx, lesions typically arise in the proximal metaphysis. Table of Contents. The fibrocartilaginous cap in subungual exostosis is hypointense on all MRI sequences, in contrast to the T2 hyperintense hyaline cartilage cap in osteochondroma. Michael L. Richardson, M.D. ~�m&3�Ӵ�N���틝فHXDKZ�����{. There is no calcification and lesions may be expansile. The articulations between these long bones include the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. Figure 3. middle and distal phalanx. The most common findings are a suggestion of a lump in the subcutaneous tissues, which may cause scalloping or erosion of the underlying bony cortex [Figure 6]. Bony abnormalities are typically pressure erosions, appearing as shallow, well- corticated osseous defects involving the distal phalangeal tufts adjacent to the tumor. Another differential for schwannoma confined to the distal phalanx is a digital mucous/mucoid cyst. Non- radiopaque foreign bodies may be detected by ultrasound aiding the surgeon in surgical removal.[39]. 0000015401 00000 n © Copyright 2021 – Indian Journal of Musculoskeletal Radiology – All rights reserved. Typically, radiographs show acro-osteolysis affecting the terminal tuft or the shaft of the distal phalanx (transverse or band acro-osteolysis) [Figure 11]. 0000001496 00000 n The metacarpals and phalanges can be divided into a proximal base, middle shaft, and distal head. CARPAL BONES. On plain radiographs, it is important to distinguish the normal aging appearance of a dense terminal tuft from a focal area of osteosclerosis. MRI is the most sensitive for early diagnosis, bone marrow edema as early as 1 day after the onset of infection can be detected. The distal phalanx epiphysis ossifies slightly later than the middle and proximal phalanges; however, fusion is usually complete before that of the middle phalanx. It is by far the most common tumor involving the distal phalanx accounting for 50% of all primary bone tumors in this anatomical region.[2]. Radiographic features suspicious for malignant transformation include cortical bone destruction, bone proliferation, and a soft tissue component. 0000069215 00000 n Due to the size of the tubular bones of the hands; however, the distinction between epiphyseal, metaphyseal, and diaphyseal is not precise and much overlap is seen.[1]. [30], Another characteristic radiographic feature of scleroderma is calcinosis [Figure 11]. endstream endobj 120 0 obj <> endobj 121 0 obj <>stream © 2019 Published by Scientific Scholar on behalf of Indian Journal of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, West Midlands. 0000009621 00000 n Foot In primates, the thumbs and big toes have two phalanges while the other digits have three phalanges. Chondroid matrix calcification tends to be seen in enchondromas of the long bones and is normally absent in hand lesions. We hope to highlight distinguishing features between these entities, allowing the radiologist to generate a clinically useful differential diagnosis. �7�P?M`5_XK8�?��y$�g��g��c�)`��Ԇ�ON]��B���Tqt�2�(G�^����f���dL[nd]��-�,Y�L.XX�t��_��G]8�%�žE��i�(�dvY,S�{�����l��B��>��9���K^Sѫ���3թFײٳ��й�6��������k��T��΢��y��_Nք�3������[d@}:D��l�Y|�����jU���d�l2G��ɋs&�$�����c?6���N�/ݮ�����)�3�g�Q�C�����*�c��w��Y����'߳�. 0000025044 00000 n Hand (Lateral View) 1st distal phalanx. 3V��=tl�W ٱ@-�ʴ�8��#����܁8����4T~@� /�� �ү�+� Through our pictorial review, we hope to demonstrate the diversity in type and number of pathologies affecting the distal phalanx and how they appear on imaging. On MRI, schwannomas tend to show low to intermediate T1 and high T2 signal with homogenous enhancement. If you continue to use this site we will assume that you are happy with it. If seen in the hand, metastases show a predilection for the distal phalanx, due to the increased arterial flow in this location. 8D) whereas the distal phalanx (P3) is the longest (Fig. phalanx; S — the caudal angle formed between a line along the dorsal surface of the hoof wall and a line along the bearing surface of the hoof; T — the caudal angle formed between a line along the Description. Shoulder. Background: Among the different breeds of horses, Asil horses with a five thousand year history have played an important role in human life. 0000075917 00000 n [38] A thorough history makes the diagnosis straightforward. Primary osteomyelitis of the distal phalanx is rare, with Staphylococcus being the most commonly involved organism. the attachment between the distal phalanx and the claw to expose the distal phalanges. Proximal phalanges are concave at the base and are dorsally convex (38). Indian J Musculoskelet Radiol 2019;1(1):47-56. 0000006470 00000 n However, many of these features are non-specific. Distally, it is firmly attached to the volar lip of the base of the middle phalanx. Several studies have shown that focal distal phalangeal osteosclerosis within the elderly is a common asymptomatic finding, especially in the mid and distal portion of the phalanx. 0000042920 00000 n 0000075395 00000 n Although most lesions of the distal phalanx are benign, it is important to exclude a possibly malignant lesion or an underlying systemic condition. It is by far the most common tumor involving the distal phalanx accounting for 50% of all primary bone tumors in this anatomical region. Schwannomas of the hand are very rare but normally appear on the volar surface with only isolated case reports of a dorsal location. [11] Given the rather similar imaging features with squamous cell carcinoma, a biopsy is usually done. [7] Keratoacanthoma is another differential, which radiographically presents as a soft tissue mass with osteolysis but with no periosteal reaction. This is typically seen as linear new bone paralleling the cortical surface with a radiolucent zone between the two. Pelvis. In some locations it can be difficult to differentiate between enchondroma and bone infarct. The phalanges /fəˈlændʒiːz/ are digital bones in the hands and feet of most vertebrates. [5], Radiographs have low sensitivity and specificity for detecting acute osteomyelitis. 0000081537 00000 n 0000075127 00000 n [28] Direct Mycobacterium leprae infection results in trabecular destruction giving a “honeycomb and cystic” appearance on radiographs. Mucous cysts are also very sharply defined, with a few reported cases showing internal septae. The most severe form, Grade 4, consists of dense, compact bone affecting the entire terminal phalanx, including the epiphysis. Patient underwent a surgical procedure to correct the amputation stump of the distal phalanx of the third finger of the left hand, showing a favorable evolution. Lesions of the Distal Phalanx: Imaging Overview. Shoulder. Radiographs , Hand , Digiti manus : Oblique view Lastly, frontal and side-views of the fingers show their bony structures and joints: proximal, middle and distal phalanges, metacarpophalangeal joints, interphalangeal joints, base, body, head and tuberosity of each … Lesions in the distal phalanx include neoplastic, autoimmune, inflammatory, and traumatic causes among a few. An award-winning, radiologic teaching site for medical students and those starting out in radiology focusing on chest, GI, cardiac and musculoskeletal diseases containing hundreds of lectures, quizzes, hand-out notes, interactive material, most commons lists and pictorial differential diagnoses T1 and T2 signal intensity on MRI is non-specific, but studies have reported thin peripheral enhancement post gadolinium contrast implying a surrounding inflammatory reaction. Table of Contents. [35] Grade 1 osteosclerosis is defined as a thickening of both bony cortices by more than 1 mm. The key to differentiating this from other lesions in a similar location is that the nail bed is not involved and there is a history of previous trauma. The classical pattern of bony mycobacterium involvement is the so-called Phemister triad of juxta-articular osteopenia, peripheral erosions, and gradual narrowing of the joint space.[24]. This is an arteriovenous anastomosis with an intervening capillary bed underlying the fingertips that regulate local temperature and circulation. Medial view of the first distal phalanx. Start studying Radiology: Hand and finger anatomy. In aging, the normal conical shape of the terminal tuft becomes more rounded and spades like appearing denser on radiographs. �ү�+� This patient demonstrates soft tissue swelling and bone destruction of the distal phalanx of the great toe due to osteomyelitis. 0000002792 00000 n A surgical sieve can aid in providing a differential diagnosis. Sarcoidosis is a granulomatous disease affecting multiple organ systems. �� 0000002075 00000 n This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Hand. 1st metacarpal. [9] The main differential is squamous cell carcinoma; indeed keratoacanthoma can undergo malignant transformation to squamous cell carcinoma with subsequent bony invasion. radius. %%EOF ,�Η� Jp,b\��5���C߫p�G,��B64���L���+mQ����=e>���SU4"��zڙ|*Rd�2΄�/���2lx�2]K `ӑSB��XVܛ�U��EϬ����0�ԉY�0QE�(������d�r��\���/�����D�J6^n�������ԉ$��%hl� �qhx4�%YC���* "oW ���ɰ���#�d�1 ��f`�H[�� ���n�� �P��!y � ck��S��f^�2�+�Rް-`w``���ôAx��7���Ws�=�6��p:00�׮�7�.b�#޺��#�ւ&a��Î����:V�~�T9��zFqBt��ܓ Figure 2. Unlike other forms of keratoacanthoma, the subungual variant shows little or no tendency to involute over time. Enchondroma is a benign, typically intramedullary tumor composed of hyaline cartilage. Radiographs with multiple views are advisable. USS usually shows a heterogeneous lesion with posterior acoustic enhancement. Subperiosteal bone resorption is often seen in hyperparathyroidism associated with chronic renal disease and is present along the radial aspect of the phalanges, especially the middle phalanx of the index and middle fingers. [37], Penetrating injuries to the hand are a common occurrence and may result in embedment of foreign bodies [Figure 16]. Most are asymptomatic but can present with pathological fractures due to severe cortical thinning. [12] The origin is most likely trauma- related, where epithelial tissue can implant itself into soft tissue or bone at the time of trauma. 165 0 obj <>stream [20] Chondrosarcoma is the most common non- metastatic primary bone malignancy of the distal phalanx presenting as a lytic lesion with popcorn calcification, endosteal scalloping, and cortical thinning.[20]. Scleroderma is a connective tissue disorder, which can cause skin tightness and decreased elasticity in the hands. Clinically, distal phalanx metastasis presents as a swollen and painful digit, often making it difficult to differentiate from infection. [5], Soft tissue chondromas are a rare differential but they have a typical soft tissue appearance on USS with no contact with the underlying bone. Methods: Each bone's position was determined after meticulous examination and correlation to an articulated skeleton relative to the image receptor and direction of the x-ray beam, with correlation to the radiograph for confirmation. The thumb (pollicis) does not consist of a middle phalanx, however, it does have two sesamoid bones. 8D). Although the respective phalanges are similarly shaped, those of Digit III are always the largest, followed by Digits IV, II, and V (Fig. Due to the impairment of local blood supply, there is often distal digital ischemia and severe sensory neuropathy. Nail and distal phalanx involvement is only usually seen in chronic disease states. 0000081607 00000 n Mycobacterium infection tends to have a predilection for the synovium and tendon sheaths compared to bone. We have presented a myriad of common and rare cases and have outlined some differentiating features between them on plain radiographs. Radiographic appearances of peripheral metastases are usually of an osteolytic, destructive lesion [Figure 7]. Ankle. Lesions of the distal phalanx often pose a radiological dilemma as the differential diagnosis is potentially broad. Ankle. There is often cortical thinning with various degrees of endosteal scalloping, but this tends to be mild when compared to other tumors. Phalanges. [11] There may be bony erosion with an osteolytic defect due to a pressure effect rather than direct tumor invasion. Saved by Lisa Holthaus. 0000063033 00000 n ulnar styloid. The radiographic findings and periosteal response are similar. 0000004596 00000 n 0000075803 00000 n Wrist. 0000005748 00000 n Search. The thumb lacks a middle phalanx. Multiple enchondromatosis, such as Ollier’s disease, have a higher risk (up to 25%) of transformation into chondrosarcoma.[4]. @��\ In the absence of a known malignancy, the lesion may resemble osteomyelitis, septic arthritis or acute monoarticular rheumatoid arthritis. It is more common in females usually presenting between 10 and 20 years of age. endstream endobj 122 0 obj <>stream On radiographs, enchondromas are typically seen as a well-defined central, lucent, expansile lesion without periosteal reaction or cortical disruption [Figure 1]. The structures of … [29] Bone resorption tends to start at the tuft and if advanced gives rise to the “penciling” appearance typical of acro-osteolysis where much of the distal phalanx may be destroyed with the fingers appearing tapered. 0000004859 00000 n startxref Knee. Soft tissue tumors ranging from benign to malignant lesions also cause erosions giving rise to a wide range of differential diagnoses. Learn vocabulary, terms, and more with flashcards, games, and other study tools. 0000049045 00000 n Inflammatory, metabolic, autoimmune, and traumatic pathologies may also present with a wide spectrum of radiological changes involving the distal phalanx. Normal anatomy of the hand. 0000009766 00000 n Anatomical atlas of the arteries and bones of the lower extremity: labeled images using 3D reconstructions and an angiographic view. Neurotropic changes result in terminal tuft resorption giving a characteristic tapered “licked candy stick” appearance [Figure 10]. Forearm. Particularly for lytic lesions, there is a concern whether an underlying primary tumor or a metastatic deposit is present. Characteristically, metastases do not cross the joint surface and so the articular cortex at the phalanx base is normally preserved, giving a “blown out,” cortical shell appearance. 0 0000015226 00000 n [28] The terminal phalanges may be involved in two ways; directly by leprotic osteomyelitis and secondarily by neurotropic changes as a consequence of neural involvement by the infective granuloma. [7], Keratoacanthoma of the distal phalanx is typically seen in the subungual space. H�\�ˊ�@�OQ��Ec���!�K7d1&3`��&F�Y�������h����~���1�߇k}�c8�]3���>�1���y��?����R�Y��1^���-�!��n������������ġ��������ý���K��0�Uh�)��K��.1�Ӳ�}����%�����GC1]ω��M��U��;�l9K�*,�ӱ�b��wߍˎ��w5d��f锲2+�y��e�"�w�o�o���i��;K���3ϑ��d.��Y�i(a(�ِ�ّ_�_���5���~�G�z�G�z�G�z�G�z�G�z�G�zd�OA��>} 0000002757 00000 n Glomus tumors are typically solitary, but multiple lesions have been associated with type 1 neurofibromatosis. If the mentioned characteristic features are not present, then MRI may be helpful. Observational studies interestingly report that more severe calcification tends to occur in the dominant hand, at sites of chronic stress such as the radial sides of fingers and soft tissue adjacent to bony protuberances implying a role of trauma in its pathogenesis. Although radiologically both are virtually indistinguishable, squamous cell carcinoma is usually seen in older patients, typically in the seventh decade compared to the fifth decade in keratoacanthoma. Features distinguishing it from osteochondroma are a lack of continuity with the underlying medullary bone and lesions tend to have an overlying fibrocartilaginous rather than a hyaline cartilage cap. [ 2] When in the phalanx, lesions … Many lesions affect the distal phalanx with overlapping imaging features. sesamoid bones metacarpals 1 4 3 2 5 phalanges distal phalanx middle phalanx proximal phalanx head base Bony Anatomy: Michael L. Richardson, M.D. The phalanges are classed as long bones. [3] Magnetic resonance imaging (MRI) typically shows a low T1 and a very high fluid-like T2 signal with linear or globular enhancement pattern along the margins of the lesion. H�\�Mn�0F�>���"��0N$�T�Db��� ��dȂ�w��R�H���A��d�1����w�WN�im�p�o�B}�kk�&�u[M���Yu�*.�q�.�M��D�8Nn�O�u�� Hand. 0000006019 00000 n The views needed to evaluate the third phalanx are different than those needed to evaluate the pastern. a well-defined lytic lesion in the hand is almost always an enchondroma. Proximal phalanges are on the first row of the phalanges of the foot. [1] The distal phalanges are unique as their proximal end has only one articular surface while their distal end terminates as a terminal tuft. [33], Brown tumors are also radiographic features seen in chronic renal disease and appear as osteolytic lesions with an eccentric or cortical location occurring in the long bones of the hands.[33]. 0000062763 00000 n Lesions are normally asymptomatic until they present with a fracture or infection. [36] These cystic areas are typically reported as having a “honeycomb,” trabeculation pattern sparing the articular joint surface. Phalangeal fractures are the most common type of hand fracture that occurs in the pediatric population and account for the second highest number of emergency department visits for fractures in the United States. The ligamentous anatomy is best assessed on coronal MR and US images. [18], Metastases in hand are rare as most involve the axial skeleton due to the increased amount of hematopoietic activity. 0000011778 00000 n Foot Typically, the history of a known primary tumor will make the diagnosis straightforward. Exposure factors of 48–52 kV and 16–20 Log in ... -numbered 1-5, laterally to medially-3 phalanges in digits 2-5-2 phalanges in first digit (thumb)-named by location= right distal phalanx of third digit. Radiography - Arm - Humerus : Shaft of humerus; Body of humerus, Surgical neck, Medial supraepicondylar ridge, Medial epicondyle, Greater tubercle, Anatomical neck. Published by Scientific Scholar on behalf of Musculoskeletal Society (MSS). 0000002931 00000 n [19], Osteomyelitis is often the result of direct inoculation from penetrating injuries or contiguous spread to the bone through soft tissues. 0000012576 00000 n This has a wide differential including sarcoidosis, rheumatoid arthritis, Hodgkin’s disease, and various hematological disorders. Discussion This patient was on systemic steroids, which predisposes to both osteomyelitis and AVN. [31], The radiographic features of renal osteodystrophy reflect hyperparathyroidism and deficiency of 1,25-dihydroxyvitamin D leading to osteomalacia, osteoporosis, soft tissue, and vascular calcifications. Lysis is traditionally associated with more serious pathologies such as malignancy and infection but is also seen in a variety of chronic systemic conditions. Radiological anatomy of the shoulder, arm, elbow, forearm, wrist, hand, and fingers. Lateral view of the distal phalanges. Tophaceous gout is typically hypo or intermediate signal intensity on T2-weighted sequences; sarcoid nodules are usually of high T2 signal intensity. MR protocol Dedicated extremity coil Triplanar nonfat suppressed PD for anatomy Additionally, the cleaned, individual bones as well as an intact manus from one specimen were digitally radiographed at the Onderste-poort Veterinary Academic Hospital Radiology Section (see above). [12], Glomus tumor represents a soft tissue hamartoma of the glomus body. Although not always seen in the phalanx, there can be underlying bone destruction leading to a cyst-like central cavity and ballooning of the remaining bone, giving a wind- filled sail appearance termed “spina ventosa.”[25] Other bony changes include coarsening of the trabecular pattern and acro-osteolysis of the distal phalanx [Figure 9]. [15] There can be an associated soft tissue mass. Apart from a lucent appearance, erosions are perhaps the most common feature, rheumatoid arthritis and gout can be wrongly attributed as the underlying cause. Proximally, the attachment of the volar plate to the proximal phalanx is more elastic and is U-shaped due to two lateral bands, which are called the “checkrein” ligaments. [32], Bone resorption in the phalangeal tufts results in loss of the cortical “white line” progressing to acro-osteolysis as discussed in previous examples [Figure 12]. The different radiological characteristics will be reviewed as well as the demographics and clinically relevant information for each lesion.
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