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Acute calcification in the fingers
Acute Calcification in the Fingers IAN A. TRAIL From the Stockport Infirmary. A patient with acute calcification of the proximal interphalangeal joint is presented to emphasize its importance in the differential diagnosis of acute infection in the finger. The diagnosis is made both clinically and by x-ray. The calcification may not be seen on standard views and oblique views may be necessary. Treatment is conservative by immobilisation and the injection of local anaesthetic. Acute calcification in the shoulder is a well recognised phenomenon. Painter (1907) was the first to diagnose a case radiologically. It has subsequently been well documented by Codman (1934). However, acute calcium deposits at other sites are much rarer. They have been described around the hip, (Gondos, 1957), around the knee, (Lamb, 1952), ankle and foot, (Gondos, 1957), the elbow, (Hughes, 1950) and in the hand, (Cohen, 1924). In the hand the majority of cases occur at the carpal and metacarpal levels. Only 8% in a series of 100 cases were at the proximal interphalangeal joint level (Carroll, 1955). A further case at this site is presented.
Case Report A forty-five-year-old woman who was employed as an Administrative Assistant presented to Casualty with a two week history of increasing pain in her left index finger, localised to the ulnar aspect of her proximal interphalangeal joint. She had previously stabbed herself with a pair of scissors at this site a month earlier. Apparently the wound had healed and she had forgotten all about it until the pain arose two weeks later. The patient was right handed. On examination she had a swollen, reddened finger which was tender over the proximal interphalangeal joint. There was no obvious nodule or fluctuant mass to be felt. Movements were grossly restricted at the proximal interphalangeal joint but limited movement was possible at the distal interphalangeal and the metacarpophalangeal joints. The patient was apyrexial and felt otherwise well at this time. X-rays taken at this time (Figures 1 and 2) revealed a calcified swelling over the ulnar and palmar aspects of the proximal interphalangeal joint. The finger was immobilised and the patient given antibiotics. The
patient
following
was
seen in the Hand Clinic on the the findings were confirmed. On
day where
Received for publication October, Ian A. Trail, F.R.C.S., Stockport
VOL.
10-B No. 2 JUNE
1985
1984. Infirmary, Stockport,
SK1 3UJ.
Fig. 1 & 2. At presentation, showing calcification at the ulnar and flexor aspects of the proximal interphalangeal joint.
close questioning it became obvious that the pain had started as a dull ache two weeks previously, progressing to a severe, throbbing pain two days before seeking medical advice. She was unable to sleep with the pain. In addition it was confirmed that the patient had no other systemic illnesses. A diagnosis of acute calcification was made at this time and the calcified area was injected with l-2ml of local anaesthetic (0.5% Lignocaine) and 0.5ml of steroid (40mg/ml Depomedrone). Splintage was continued but the antibiotics were stopped. The patient was reviewed weekly, and at two weeks the pain had completely subsided. Splintage was discarded and mobilisation begun. Blood results at this time were as follows:White cell count E.S.R. R.A. Latex S.C.A.T.
3.7 x 103/l 1Omm in one hour Negative Negative 263
IAN
Calcium (albumin corrected) Phosphate Alkaline phosphatase Uric acid
A. TRAIL
2.20mmol/l l.l6mmol/ 1 6Oiu/ 1 0.294mmol/l
Hamilton (1951), Oldfield (1951), Gondos (1951), Martin (1951), Yelton (1958), Hitchcock (1959), Strandell (1963), Thompson (1968), Swannell (1969), Hauptman (1970), Watson (1980), Gravanis (1983) and Selby (1984).
Further x-rays (Figures 3 and 4) were taken one month later and these showed a regression of the calcified area. Final x-rays (Figures 5 and 6) taken ten months after presentation revealed complete resolution of the calcification.
Fig. 5 & 6 Final X-rays, resolution.
at
ten
months,
showing
complete
Aetiology
Fig. 3 & 4 One month later, showing regression.
Discussion
Acute calcification in the hand can occur at three main sites; the carpus, the metacarpophalangeal region and in the digits. Carroll (1955) in his review of 100 cases had only eight cases at the proximal interphalangeal joint and five at the distal interphalangeal joint of the fingers, the rest being at the carpal and metacarpophalangeal levels with the commonest site being the insertion of flexor carpi ulnaris at the pisiform bone. They suggest that acute calcification in the hand is more common and is frequently overlooked. Whilst this may be true in the rest of the hand a review of previous and subsequent literature does not confirm this in the fingers. In 1938 Sandstrom reported six cases in the digits out of a total of 329 cases throughout the body. He did not, however, locate them precisely. Thirty-eight further cases are reported of acute calcification in the fingersJansen (1943), Vasko (1946), De Palma (1947), 264
The aetiology of acute calcification anywhere in the body is still uncertain. The original theory (Moschowitz, 1915) was that stress or strain of the structure leads to a localised necrosis with a resultant deposition of calcium phosphate and oxalate crystals. The deposition occurs because of the localised alkalinity of the necrotic tissue. The calcium salts themselves are locally irritating to the tissues resulting in an inflammatory response with pain. This theory has now been challenged on two points. Firstly, the role of trauma in this condition is uncertain. Many cases (Vasko, De Palma, Carroll) gave no history of trauma. A few (Codman, Cooper) gave a history of minor trauma and others (Hamilton, Oldfield) of repetitive minor trauma. Secondly, the pathological studies performed more recently on these areas reveal no evidence of scarring, a consequence of necrosis, or of an acute inflammatory response. Uhtholt (1976) postulates that there is a local transformation of tissue into fibrocartilage. The transformation was probably due to increased hydrostatic pressure and a lowering of the tissue oxygen tension. The chondrocytes present mediate the deposition of calcium crystals. They describe acute calcification, not as a degenerative but as THE JOURNAL
OF HAND
SURGERY
ACUTE CALCIFICATION IN THE FINGERS
a reactive process. They further divide it into two phases; formative and resorptive. The resorptive phase being characterised by the accumulation of phagocytes around the individual foci. Gravanis (1983) did not find any calcification within the tendon itself but in the surrounding hyperplastic synovium described as containing psammoma-like calcifications. They postulate that these calcific bodies are a reaction of the synovium to a primary tendinous lesion which may be a consequence of ischaemia or mild trauma. Other authors, however, have found similar calcific bodies lying within tendon and ligament (Pedersen, 1951). Finally, some authors (Greene, 1980) have proposed that acute calcification may be similar to other crystalinduced diseases such as gout and pseudo-gout. This is based on the fact that clinically they can closely resemble these conditions and that they have been recurrent and multi-focal (Seidenstein, 1950; Strandell, 1963). However, in virtually all cases biochemical profiles have been reported as normal and while metastatic calcification is seen in hypercalcaemia and in patients on renal dialysis, hypercalcaemia is not found in acute calcification. The association of collagen disease such as scleroderma and dermatomyositis with periarticular calcification is well established but again acute calcification is not a feature of these conditions. Bacterial infection is certainly not the cause of acute calcification as all reports give a negative culture. One patient (De Palma) had had acute tonsillitis within twelve months of presentation however. It should be said that nearly all the work on aetiology of acute calcification has been done at the shoulder joint. Clinical Features The condition in the fingers seems to affect women more than men, the ratio being 5:2 of the cases where sex is given. Ages range from 15-57. No particular occupation seems to predispose nor is there any difference between heavy, normal and lighter occupations. The lesion more often involves the dominant hand in the cases reported and where the finger is named the index is the most commonly involved. The proximal interphalangeal joint was involved in twenty-nine out of the thirty-seven where the joint was named. Pain is the most striking symptom. Every reported case experienced pain. Often it was of acute onset, severe and throbbing in nature (Cooper, Carroll) but many VOL. 10-B No. 2 JUNE 1985
patients also experienced a prodromal ache for anything up to six months prior to presentation (Hamilton, Oldfield, Pollen; 1961). Swelling was also a frequent sign. This was often diffuse (Hitchcock and Langton, Pollen) but with a localised tender nodule at the exact site of the pain (Carroll). Joint movements were always restricted. Pyrexia was present in two cases involving a finger (Hamilton, Selby). The rest had no systemic symptoms. Most cases lasted for a maximum (Carroll, De Palma).
of three weeks
Many of the above clinical features are shared by infective lesions of the finger e.g. cellulitis, suppurative arthritis, infected foreign bodies and insect bites. However, the lack of systemic symptoms and axillary lymphadenopathy, the absence of skin abrasions together with the characteristic radiological appearances should enable one to make the diagnosis of acute calcification. Other conditions to be excluded are crystalline diseases such as gout or pseudo-gout, trauma and an acute exacerbation of rheumatoid arthritis or another connective tissue disorder. Radiological Features It is important to include oblique views in addition to true antero-posterior and lateral ones as many deposits can be small and difficult to see. The maximum point of tenderness localises the deposit well. If the correct views are taken the diagnosis is made by x-ray. The deposit may be ill-defined (De Palma) or well-defined (Sandstrbm, Gondos, Pollen). It is said that the more well-defined a deposit the more mature the lesion. The size in recorded cases can vary quite markedly from 3mm to 2cm. The shape can also vary from circular to linear, probably depending upon the structure involved. It is said that in the fingers the supporting structures around the joint are more frequently involved. Evidence for this is mainly radiological, however. Certainly in three of the cases reviewed the authors gave tendon or tendon sheath as the site. The radiological appearances tend to persist usually up to three months although Pollen reported a case where these lasted for twelve months. Treatment Many modes of treatment have been used in the past; short-wave diathermy (Pollen), ultra-violet light (Neff, 1951), heat (Carroll) and radiotherapy (Martin, Sandstrom). However, the basis of successful treatment would appear to be immobilisation (Carroll, Hitchcock and Langton, De Palma) until the pain has resolved. 265
IAN A. TRAIL
The injection of local anaesthetic would also appear to be beneficial (Greene, Selby). Results are dramatic, pain relief is achieved quickly and is long-lasting. The reason for the long-lasting relief is uncertain but, from the literature, injection of local anaesthetic does seem to shorten the normal clinical course (Carroll). It may be that local anaesthetic improves the circulation to the part and increases the local oxygen tension, thus aiding in resorption of the calcium. Local steroid injections are a little more controversial. Overall they do not seem to add any advantage over local anaesthetic alone and are well known to cause local necrosis (Balasubramanian, 1972), a possible disadvantage. Operative intervention in the fingers is rarely indicated in this self-limiting disease. Carroll reported immediate relief within twenty-four hours but confirm that indications are few. Operative details are scanty but the calcification is said to be close to the capsule of the interphalangeal joint or within the flexor sheath (Strandell, Gravanis). Various non-steroidal anti-inflammatory agents have been used ranging from aspirins to phenylbutazone and naproxen (Yelton, Thompson, Green, Selby) all with reported success, pain often subsiding within four to five days.
Acknowledgements
I would like to thank Mr. H. Bolton, Ch.M., F.R.C.S. for his permission to study his patient and also to thank Miss Anne Paulson for secretarial help and for typing the manuscript.
References BALASUBRAMANIAM, P. and PRATHAP, K. (1972). The Effect of Injection of Hydrocortisone into Rabbit Calcaneal Tendons. The Journal of Bone and Joint Surgery, 54B: 729-734. CARROLL, R. E., SINTON, W. and GARCIA, A. (1955). Acute Calcium Deposits in the Hand. The Journal of the American Medical Association, 157: 422-426. CODMAN, E. A. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa, Boston, Thomas Todd (1934). COHEN, I. (1924). Calcareous Deposit at the Insertion of Flexor Carpi Ulnaris Tendon Following Trauma. American Journal Surgery, 38: 172-173. COOPER, W. (1942). Calcareous Tendinitis in the Metacarpo-Phalangeal Region. The Journal of Bone and Joint Surgery, 24: 114-122.
266
DE PALMA, A. F. (1947). Calcareous Deposits in Soft Tissues about the Proximal Interphalangeal Joint of the Index Finger. The Journal of Bone and Joint Surgery, 29: 808-809. GONDOS, B. (1957). Observations on Periarthritis Calcarea. American Journal of Roentgenology and Radium Therapy and Nuclear Medicine, 77: 93-108. GRAVANIS, M. B. and GAFFNEY, E. F. (1983). Idiopathic calcifying tenosynovitis. Histopathologic features and possible pathogenesis. American Journal of Surgical Pathology, 7: 357-361. GREENE, T. L. and LOUIS, D. S. (1980). Calcifying Tendinitis in the Hand. Annals of Emergency Medicine, 9: 438.440. HAMILTON, A. R. (1951). Calcinosis. The Journal of Bone and Joint Surgery, 33B: 572-577. HAUPTMAN, H. A. (1970). Acute Tendinitis Calcarea. New York State Journal of Medicine, 70: 955.961. HITCHCOCK, E. R. and LANGTON, L. (1959). Peritendinitis Calcarea with Special Reference to the Hand. Journal of the Faculty of Radiologists, 10: 86-94. HITCHCOCK, H. H. (1937). Calcium Deposits About Joints. Western Journal of Surgery Obstetrics and Gynecology 45: 353-361. HUGHES, E. S. R. (1950). Acute Deposition of Calcium Near the Elbow. The Journal of Bone and Joint Surgery, 32B: 30-34. JANSEN, K. F. (1943). Calcareous Peritendinitis. Two Cases with Localisation to the Fingers. Acta Radiologica, 24: 285-288. LAMB, D. W. (1952). Deposition of Calcium Salts in the Medial Collateral Ligament of the Knee. The Journal of Bone and Joint Surgery, 34B: 233-235. MARTIN, J. F. and BROGDON, B. G. (1957). Peritendonitis Calcarea of the Hand and Wrist. American Journal of Roentgenology and Radium Therapy and Nuclear Medicine, 78: 74-85. MOSCHOWITZ, E. (1915). Histopathology of Calcification of Spinatus Tendons as Associated with Subacromial Bursitis. American Journal of Medical Science, 150: 115.126. NEFF, F. E. and ANDERSON, C. M. (1951). The Use of Ultra Violet Blood Irradiation in the Treatment of Bursitis and Tendinitis C&area. American Journal of Surgery, 81: 622-628. OLDFIELD, M. C. (1951). “Tennis Thumb”. Tendinitis with Calcification in Flexor PolIicis Longus. Lancet 1: 1151. PAINTER, C. F. (1907). Subdeltoid Bursitis. Boston Medical Surgical Journal, 156: 345-349. PEDERSEN, H. E. and KEY, J. A. (1951). Pathology of Calcareous Tendonitis and Subdeltoid Bursitis. Archives of Surgery, 62: 50-63. POLLEN, A. G. (1961). Calcareous Deposits about the Metacarpo-Phalangeal Joints. The Journal of Bone and Joint Surgery, 43B: 251-255. SANDSTROM, C. (1938). Peritendonitis Calcarea. A Common Disease of Middle Life; Its Diagnosis, Pathology and Treatment. The American Journal of Roentgenology and Radium Therapy, 40: l-21. SEIDENSTEIN, H. (1950). Acute Pain in the Wrist and Hand Associated with Calcific Deposits. The Journal of Bone and Joint Surgery, 32A: 413-418. SELBY, C. L. (1984). Acute Calciiic Tendinitis of the Hand: An infrequently recognised and frequently misdiagnosed form of periarthritis. Arthritis and Rheumatism, 27: 337. STRANDELL, G. (1963). Peritendinitis Calcarea in the Hand. Acta Chirurgica Scandinavica, 125: 42-5 1. SWANNELL, A. J. and DIXON, A. St. J. (1969). Extra-articular Calcification mimicking Acute Arthritis. Annals of the Rheumatic Diseases, 28: 678-679. THOMPSON, G. R., TING, Y. M., RIGGS, G. A., FENN, M. E. and DENNING, R. M. (1968). Calcific Tendinitis and Soft-Tissue Calcification Resembling Gout. The Journal of the American Medical Association, 203: 464472. UHTHOFF, H. K., SARKAR, K. and MAYNARD, J. A. (1976). Calcifying Tendinitis: A New Concept of Its Pathogenesis. Clinical Orthopaedics and Related Research, 118: 164168. VASKO, J. R. (1946). Calcareous Tendinitis of a Flexor Tendon of the Finger. The Journal of Bone and Joint Surgery, 28: 638-640. WATSON, F. M. and PURVIS, J. M. (1980). Acute Calcareous Deposits of the Hand and Wrist. Southern Medical Journal, 73: 150. YELTON, C. L. and DICKEY, L. E. (1958). Calcification about the Hand and Wrist. Southern Medical Journal, 51: 489-495.
THE JOURNAL OF HAND SURGERY
Case Report A forty-five-year-old woman who was employed as an Administrative Assistant presented to Casualty with a two week history of increasing pain in her left index finger, localised to the ulnar aspect of her proximal interphalangeal joint. She had previously stabbed herself with a pair of scissors at this site a month earlier. Apparently the wound had healed and she had forgotten all about it until the pain arose two weeks later. The patient was right handed. On examination she had a swollen, reddened finger which was tender over the proximal interphalangeal joint. There was no obvious nodule or fluctuant mass to be felt. Movements were grossly restricted at the proximal interphalangeal joint but limited movement was possible at the distal interphalangeal and the metacarpophalangeal joints. The patient was apyrexial and felt otherwise well at this time. X-rays taken at this time (Figures 1 and 2) revealed a calcified swelling over the ulnar and palmar aspects of the proximal interphalangeal joint. The finger was immobilised and the patient given antibiotics. The
patient
following
was
seen in the Hand Clinic on the the findings were confirmed. On
day where
Received for publication October, Ian A. Trail, F.R.C.S., Stockport
VOL.
10-B No. 2 JUNE
1985
1984. Infirmary, Stockport,
SK1 3UJ.
Fig. 1 & 2. At presentation, showing calcification at the ulnar and flexor aspects of the proximal interphalangeal joint.
close questioning it became obvious that the pain had started as a dull ache two weeks previously, progressing to a severe, throbbing pain two days before seeking medical advice. She was unable to sleep with the pain. In addition it was confirmed that the patient had no other systemic illnesses. A diagnosis of acute calcification was made at this time and the calcified area was injected with l-2ml of local anaesthetic (0.5% Lignocaine) and 0.5ml of steroid (40mg/ml Depomedrone). Splintage was continued but the antibiotics were stopped. The patient was reviewed weekly, and at two weeks the pain had completely subsided. Splintage was discarded and mobilisation begun. Blood results at this time were as follows:White cell count E.S.R. R.A. Latex S.C.A.T.
3.7 x 103/l 1Omm in one hour Negative Negative 263
IAN
Calcium (albumin corrected) Phosphate Alkaline phosphatase Uric acid
A. TRAIL
2.20mmol/l l.l6mmol/ 1 6Oiu/ 1 0.294mmol/l
Hamilton (1951), Oldfield (1951), Gondos (1951), Martin (1951), Yelton (1958), Hitchcock (1959), Strandell (1963), Thompson (1968), Swannell (1969), Hauptman (1970), Watson (1980), Gravanis (1983) and Selby (1984).
Further x-rays (Figures 3 and 4) were taken one month later and these showed a regression of the calcified area. Final x-rays (Figures 5 and 6) taken ten months after presentation revealed complete resolution of the calcification.
Fig. 5 & 6 Final X-rays, resolution.
at
ten
months,
showing
complete
Aetiology
Fig. 3 & 4 One month later, showing regression.
Discussion
Acute calcification in the hand can occur at three main sites; the carpus, the metacarpophalangeal region and in the digits. Carroll (1955) in his review of 100 cases had only eight cases at the proximal interphalangeal joint and five at the distal interphalangeal joint of the fingers, the rest being at the carpal and metacarpophalangeal levels with the commonest site being the insertion of flexor carpi ulnaris at the pisiform bone. They suggest that acute calcification in the hand is more common and is frequently overlooked. Whilst this may be true in the rest of the hand a review of previous and subsequent literature does not confirm this in the fingers. In 1938 Sandstrom reported six cases in the digits out of a total of 329 cases throughout the body. He did not, however, locate them precisely. Thirty-eight further cases are reported of acute calcification in the fingersJansen (1943), Vasko (1946), De Palma (1947), 264
The aetiology of acute calcification anywhere in the body is still uncertain. The original theory (Moschowitz, 1915) was that stress or strain of the structure leads to a localised necrosis with a resultant deposition of calcium phosphate and oxalate crystals. The deposition occurs because of the localised alkalinity of the necrotic tissue. The calcium salts themselves are locally irritating to the tissues resulting in an inflammatory response with pain. This theory has now been challenged on two points. Firstly, the role of trauma in this condition is uncertain. Many cases (Vasko, De Palma, Carroll) gave no history of trauma. A few (Codman, Cooper) gave a history of minor trauma and others (Hamilton, Oldfield) of repetitive minor trauma. Secondly, the pathological studies performed more recently on these areas reveal no evidence of scarring, a consequence of necrosis, or of an acute inflammatory response. Uhtholt (1976) postulates that there is a local transformation of tissue into fibrocartilage. The transformation was probably due to increased hydrostatic pressure and a lowering of the tissue oxygen tension. The chondrocytes present mediate the deposition of calcium crystals. They describe acute calcification, not as a degenerative but as THE JOURNAL
OF HAND
SURGERY
ACUTE CALCIFICATION IN THE FINGERS
a reactive process. They further divide it into two phases; formative and resorptive. The resorptive phase being characterised by the accumulation of phagocytes around the individual foci. Gravanis (1983) did not find any calcification within the tendon itself but in the surrounding hyperplastic synovium described as containing psammoma-like calcifications. They postulate that these calcific bodies are a reaction of the synovium to a primary tendinous lesion which may be a consequence of ischaemia or mild trauma. Other authors, however, have found similar calcific bodies lying within tendon and ligament (Pedersen, 1951). Finally, some authors (Greene, 1980) have proposed that acute calcification may be similar to other crystalinduced diseases such as gout and pseudo-gout. This is based on the fact that clinically they can closely resemble these conditions and that they have been recurrent and multi-focal (Seidenstein, 1950; Strandell, 1963). However, in virtually all cases biochemical profiles have been reported as normal and while metastatic calcification is seen in hypercalcaemia and in patients on renal dialysis, hypercalcaemia is not found in acute calcification. The association of collagen disease such as scleroderma and dermatomyositis with periarticular calcification is well established but again acute calcification is not a feature of these conditions. Bacterial infection is certainly not the cause of acute calcification as all reports give a negative culture. One patient (De Palma) had had acute tonsillitis within twelve months of presentation however. It should be said that nearly all the work on aetiology of acute calcification has been done at the shoulder joint. Clinical Features The condition in the fingers seems to affect women more than men, the ratio being 5:2 of the cases where sex is given. Ages range from 15-57. No particular occupation seems to predispose nor is there any difference between heavy, normal and lighter occupations. The lesion more often involves the dominant hand in the cases reported and where the finger is named the index is the most commonly involved. The proximal interphalangeal joint was involved in twenty-nine out of the thirty-seven where the joint was named. Pain is the most striking symptom. Every reported case experienced pain. Often it was of acute onset, severe and throbbing in nature (Cooper, Carroll) but many VOL. 10-B No. 2 JUNE 1985
patients also experienced a prodromal ache for anything up to six months prior to presentation (Hamilton, Oldfield, Pollen; 1961). Swelling was also a frequent sign. This was often diffuse (Hitchcock and Langton, Pollen) but with a localised tender nodule at the exact site of the pain (Carroll). Joint movements were always restricted. Pyrexia was present in two cases involving a finger (Hamilton, Selby). The rest had no systemic symptoms. Most cases lasted for a maximum (Carroll, De Palma).
of three weeks
Many of the above clinical features are shared by infective lesions of the finger e.g. cellulitis, suppurative arthritis, infected foreign bodies and insect bites. However, the lack of systemic symptoms and axillary lymphadenopathy, the absence of skin abrasions together with the characteristic radiological appearances should enable one to make the diagnosis of acute calcification. Other conditions to be excluded are crystalline diseases such as gout or pseudo-gout, trauma and an acute exacerbation of rheumatoid arthritis or another connective tissue disorder. Radiological Features It is important to include oblique views in addition to true antero-posterior and lateral ones as many deposits can be small and difficult to see. The maximum point of tenderness localises the deposit well. If the correct views are taken the diagnosis is made by x-ray. The deposit may be ill-defined (De Palma) or well-defined (Sandstrbm, Gondos, Pollen). It is said that the more well-defined a deposit the more mature the lesion. The size in recorded cases can vary quite markedly from 3mm to 2cm. The shape can also vary from circular to linear, probably depending upon the structure involved. It is said that in the fingers the supporting structures around the joint are more frequently involved. Evidence for this is mainly radiological, however. Certainly in three of the cases reviewed the authors gave tendon or tendon sheath as the site. The radiological appearances tend to persist usually up to three months although Pollen reported a case where these lasted for twelve months. Treatment Many modes of treatment have been used in the past; short-wave diathermy (Pollen), ultra-violet light (Neff, 1951), heat (Carroll) and radiotherapy (Martin, Sandstrom). However, the basis of successful treatment would appear to be immobilisation (Carroll, Hitchcock and Langton, De Palma) until the pain has resolved. 265
IAN A. TRAIL
The injection of local anaesthetic would also appear to be beneficial (Greene, Selby). Results are dramatic, pain relief is achieved quickly and is long-lasting. The reason for the long-lasting relief is uncertain but, from the literature, injection of local anaesthetic does seem to shorten the normal clinical course (Carroll). It may be that local anaesthetic improves the circulation to the part and increases the local oxygen tension, thus aiding in resorption of the calcium. Local steroid injections are a little more controversial. Overall they do not seem to add any advantage over local anaesthetic alone and are well known to cause local necrosis (Balasubramanian, 1972), a possible disadvantage. Operative intervention in the fingers is rarely indicated in this self-limiting disease. Carroll reported immediate relief within twenty-four hours but confirm that indications are few. Operative details are scanty but the calcification is said to be close to the capsule of the interphalangeal joint or within the flexor sheath (Strandell, Gravanis). Various non-steroidal anti-inflammatory agents have been used ranging from aspirins to phenylbutazone and naproxen (Yelton, Thompson, Green, Selby) all with reported success, pain often subsiding within four to five days.
Acknowledgements
I would like to thank Mr. H. Bolton, Ch.M., F.R.C.S. for his permission to study his patient and also to thank Miss Anne Paulson for secretarial help and for typing the manuscript.
References BALASUBRAMANIAM, P. and PRATHAP, K. (1972). The Effect of Injection of Hydrocortisone into Rabbit Calcaneal Tendons. The Journal of Bone and Joint Surgery, 54B: 729-734. CARROLL, R. E., SINTON, W. and GARCIA, A. (1955). Acute Calcium Deposits in the Hand. The Journal of the American Medical Association, 157: 422-426. CODMAN, E. A. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa, Boston, Thomas Todd (1934). COHEN, I. (1924). Calcareous Deposit at the Insertion of Flexor Carpi Ulnaris Tendon Following Trauma. American Journal Surgery, 38: 172-173. COOPER, W. (1942). Calcareous Tendinitis in the Metacarpo-Phalangeal Region. The Journal of Bone and Joint Surgery, 24: 114-122.
266
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