Heterotopic para-articular ossification of the proximal interphalangeal joint

The Journal of HAND SURGERY

Lindstriim and Nystrtim

situations in which the preservation of a finger with a mobile MP joint is desired.4. 5 In cases such as the one presented here, the combination of bone cement and a silicone joint implant may be a satisfactory alternative to a ray amputation. The technique is safe and simple, and the implanted material is an excellent tissue spacer. The combination of bone cement and silicone might therefore be considered as a temporary solution when a definite reconstruction is desired but cannot be performed at the time of the primary surgery. REFERENCES 1.

2.

3. 4. 5. Fig. 3. Photograph taken 8 years after surgery. There is no

Posner MA. Ray transposition for central digital loss. J HAND SURG 1979;4:242-57. Hagert CG. Implants designed for finger joints: a roentgenographic study and a study of implant wear and tear; an experimental study. Stand J Plast Reconstr Surg 1975;9:53-63. Hagert CG. Advances in hand surgery: finger joint implants. Surg Annu 1978;10:253-75. Menon J. Reconstruction of the metacarpophalangeal joint with autogenous metatarsal. J HAND SURG 1983;8:443-6. Tsai T-M, Jupiter JB, Kutz JE, Kleinert HE. Vascularized autogenous whole joint transfer in the hand: A clinical study. J HAND SURG 1982;7:335-42.

perceivable skin reaction to the underlying bone cement.

Heterotopic para-articular ossification of the proximal interphalangeal joint A 24-year-old woman sustained a closed head injury. She regained consciousness over a 2-month period hut heterotopic ossification developed around both elbows and the proximal interphalangeal joints of her left ring and long fingers. The new hone was allowed to mature and was subsequently

resected from both elbows and the fingers with substantial

improvement

in func-

tion. There is no clear explanation for the formation of such heterotopic bone. (J HAND SURC 1992;17k154-7.)

Marc Asselmeier,

MD, and Terry R. Light, MD, Maywood, Ill.

From the Department of Orthopaedic Surgery and Rehabilitation, Loyola University School of Medicine, Maywood. Ill. Received for publication June 5, 1990.

March 24, 1989; accepted

in revised form

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Terry R. Light, MD, Department of Orthopaedic Surgery and Rehabilitation, Loyola University School of Medicine, 2160 S. First Ave., Maywood, IL 60153. 311123619

154

THE JOURNAL OF HAND SURGERY

C

alcification in peri-articular and paraarticular locations may occur in association with tumoral calcinosis, psuedogout, trauma, and renal failure. True heterotopic new bone formation is seen less commonly and may occur in association with conditions such as spinal cord injury and coma,’ as well as bums.2 The hip, knee, shoulder, and elbow are the most common sites of involvement. We describe a case report of heterotopic ossification involving the fingers after a closed head injury.

Vol. 17A, No. I January 1997

Weterotopit

ossifcution

@“proximal interphalangeat juinf

155

Fig. 1. Preoperative radiographs. A, PA view of the left hand showing ankylosing of the ring and long finger PIP joints. B, Lateral view of the left ring finger.

Case report A 24-year-old right-handed woman sustained a closed head injury in a motor vehicle accident. Computed tomography CT scan showed right interventricular hemorrhage and bifrontal contusion. Associated injuries included facial and mandibular fractures, renal contusion, and a nondisplaced fracture of the left small finger proximal phalanx. Her postinjury period was complicated by pneumonia requiring intravenous antibiotics. Feeding gastrostomy was required for metabolic support. Serum calcium, phosphorus, alkaline phosphatase levels, and renal function studies were all within the normal range. The small finger was splinted for 2 weeks. Physical therapy was then started to maintain motion in all joints. Over the 2 months following her injury, she gradually regained consciousness, complaining of bilateral elbow pain as she awoke. Examination showed a limited range of motion (ROM), with x-ray films demonstrating early heterotopic ossification about both elbows. Treatment with nonsteroidal antiinflammatory medication and etidronate disodium (Didronel. Norwich Eaton) was begun. Progressive stiffness of the ring and long fingers of the left hand was observed. X-ray films showed early para-articular ossification about the ring and long proximal interphalangeal (PIP) joints. Despite drug therapy, the multifocal heterotopic ossification progressed. Both elbows became ankylosed while the PIP joints of her left long and ring fingers became fixed at 65 degrees of Rexion several months after the accident. After being judged radiographically mature, the heterotopic ossi-

fication around the elbow was resected by another surgeon with considerable improvement of elbow motion. Hand radiographs taken 5 months after injury showed mature para-articular heterotopic ossification along the palmar and ulnar aspects of the PIP joints (Fig. I). The joint space was preserved in each finger. Her functional capability had substantially improved and her major residual limitations involved her left hand. Through ulnar midlateral incisions, a bony bridge was defined that spanned the palmar ulnar aspect of the long and proximal phalanges of both fingers. Heterotopic bone had replaced the palmar plate and ulnar accessory collateral ligament in each finger. After resecting the heterotopic ossification with the covering periosteum, the PIP joints could be passively flexed to 100 degrees and extended to within 10 degrees of full extension intraoperatively. The articular cartilage appeared normal and viable. Both fingers were stable to ulnar collateral ligament stress. Indomethacin S.R. (E. R. Squibb and Sons, Inc.), 75 mg orally taken daily was begun immediately after the operation and continued for 6 weeks. Motion was begun 5 days after operation with passive extension assist splinting. Therapy concentrated on achieving an active range of motion. Follow-up more than 6 months after operation demonstrates no recurrence of the para-articular ossification (Fig. 2). She actively flexes each PIP joint to 105 degrees and lacks only 10 degrees extension in the ring and 30 degrees in the long PIP joint.

156

The Journal of HAND SURGERY

Asselmeier and Light

Fig. 2. Postoperative

radiographs.

A, PA view of the left long and ring fingers. B, Lateral

view.

Discussion This patient had no evidence of crystal-induced diseases. These conditions tends to be recurrent, multifocal, and have an inflammatory clinical picture.3 Although she did sustain a renal contusion, hypercalcemia did not develop nor did she require dialysis. Acute calcification around the PIP joints has been reported after trauma.4 Acute calcification usually resolves with conservative treatment. This woman was white and had normal serum calcium, phosphorus and alkaline phosphatase values. She also had no family history of similar problems or evidence of hydroxyapatite crystals, thus the diagnosis of tumoral calcinosis was unlikely.5 In a series of 447 paralyzed patients reported by Wharton and Morgan6 only three of the 321 total joints complicated by heterotopic ossification were in the hand. The authors note that none of the involved hands had finger joint ankylosis. They observed that when heterotopic ossification developed within 6 months after injury in patients under 35 years of age there was a higher incidence of ankylosis. Henderson and Reid’ reported two cases of heterotopic para-articular ossification causing partial digital ankylosis of the fingers. The first followed severe head

injury and involved six joints in three fingers. When one of those joints was explored, the profundus tendon was noted to be invaded by bone. This was resected with return of some PIP motion before being complicated by a wound infection and recurrence of joint stiffness. The other case involved a patient with incomplete tetraplegia whose ring and long finger PIP joints had become ankylosed in extension. Surgical excision of the bone included resection of the collateral ligaments. No recurrence of bone formation was seen on postoperative x-ray films. Passive movement was reported to be within a “useful range.” In this patient, serial radiographs demonstrated mature bone formation at the PIP level. Since previous elbow resections had proven effective, digital releases were undertaken with the goal of improving PIP position and possibly motion. A bone scan was not done in this case, but may prove beneficial in judging the maturity of heterotopic ossification. The explanation of the new bone formation that occurs with heterotopic ossification is clouded by the variety of settings in which it occurs. Calcium metabolism is altered at the cellular level. Immobilization or changes in neurogenic and hormonal activity lead to

Vol. l7A. No. 1 January 1992

Heterotopic

the differentiation of mesenchymal or osteogenically derived osteoblasts. ’ Many reports have documented a high incidence of heterotopic ossification after neurologic insult. Very few cases involve the hand. The timing and nature of both pharmacologic and physical therapy measures in the prevention of this disorder remain the subject of debate. Surgical resection of the heterotopic ossification can be an effective element in the management of these patients when the bone has matured. In the rare instance in which para-articular heterotopic ossification limits digital motion. resection may improve motion.

3.

4. 5. 6. 7. 8.

REFERENCES 1. Jensen LJ, Halar E, Little JW, Brooke MM. Special re9.

view: neurogenic heterotopic ossification. Am J Phys Med 1988;66(3):35 I-63. 2. Vorenkamp SE, Nelson TL. Ulnar nerve entrapment due

ossification

of proximal interphalan,~ed joint

to heterotopic bone formation after a severe bum. 3 HAND SURG 3987;32A(3):378-80. Ishikawa K, Higashi I, Shimomura Y, Yonemura K. Deposition of calcium pyrophosphate dihydrate crystals in the hand. J HAND SURG 1988;13A(6):943-8. Trail IA. Acute calcification in the fingers. J HAND SURC~ 1985;10B(2):263-6. Bogumill GP, Lloyd RJ. Tumoral calcinosis in multiple digits: a case report. J HAND SURG 1985;10A(5):739-43. Wharton GW, Morgan TH. Ankylosis in the paralyzed patient. J Bone Joint Surg 1970;52A:l05-12. Henderson JP. Reid DAC. Para-articular ossification in the hand. Hand 1981;13(3):239-45. Lynch C. Pont A. Weingarden SI. Heterotopic ossification in the hand of a patient with spinal cord injury. Arch Phys Med Rehab 1981;62:291-2. Lee 1Y. Rossier AB. Heterotopic ossification in the hand. Arch Phys Med Rehab 1982:63:96.

A biomechanical study of the collateral ligaments of the proximal interphalangeal joint Collateral

ligament

injuries of the proximal

interphalangeal

joint are common.

A significant

number of these injuries result in complete rupture of the ligament. The forces that damage the ligaments gulation,

are abduction

and adduction

stresses. Previous studies have investigated

and patterns of failure, but detailed biomechanical

eight proximal interphalangeal

joints from fresh human cadaver fingers (average age, 67 years)

were stressed at velocities of 1 mm/set,

4 mmlsec,

and 10 mm/set.

done. Four distinct rupture patterns were noted: midsubstance detachment,

laxity, an-

rupture studies are scant. SixtySectioning studies were also

tear, proximal detachment,

distal

and distal avulsion fracture. The prevalence of these patterns differed with the rate

at which the ligaments were stressed. Lower speeds tended to produce midsubstance

tears, while

higher speeds yielded distal damage. The study confirmed that the lateral collateral ligament is the primary

restraint

against medial-lateral

stress and that other supporting

extensor hood and the palmar plate) did not contribute significantly

structures

to side-to-side

(the

stability.

(J HAND SURC 1992;17A:157-63.)

Robert Y. Rhee, MD, George Reading, MD, and R. Christie Wray, MD, Rochesrer. N.Y.

From the Department of Surgery, University of Rochester School of Medicine. Strong Memorial Hospital, Rochester, N.Y. Received for publication April 19, 1991.

July 3 1, 1990; accepted

in revised form

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: George Reading, MD, Department of Surgery, University of Rochester Medical Center. Rochester, NY 14642. 3/I/31032

I njuries to the collateral ligaments of the proximal interphalangeal joint are common. ‘-j Generally, they are not considered major, and they are often treated simply as sprains.‘. 4 The injury may vary considerably, however, from a mild strain to a severe, disabling clinical condition with complete rupture of the ligament and side-to-side joint instability. This injury, even when properly treated, may result in prolonged pain, stiffness, and swelling.5

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