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In aging, the normal conical shape of the terminal tuft becomes more rounded and spades like appearing denser on radiographs. [12] The origin is most likely trauma- related, where epithelial tissue can implant itself into soft tissue or bone at the time of trauma. 0000081607 00000 n The presence of sequestration and lack of osteopenia tend to favor pyogenic over the tuberculous infection. Shoulder. The articulations between these long bones include the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. Nail and distal phalanx involvement is only usually seen in chronic disease states. Schwannomas of the hand are very rare but normally appear on the volar surface with only isolated case reports of a dorsal location. [18], Metastases in hand are rare as most involve the axial skeleton due to the increased amount of hematopoietic activity. �ү�+� The thumb, unlike other fingers, has only two phalanges: the proximal phalanx and the distal phalanx. A periosteal reaction is unusual and joint involvement is rare. Proximal phalanges are on the first row of the phalanges of the foot. [5], Radiographs have low sensitivity and specificity for detecting acute osteomyelitis. [14], As the tumor is extrinsic to bone, there may not be any radiographic findings as bony involvement is less common than pure soft tissue involvement. Michael L. Richardson, M.D. 0000011948 00000 n Sarcoidosis is a granulomatous disease affecting multiple organ systems. The most frequent intraosseous abnormality is a “lacy,” lytic like appearance akin to small bone cysts [Figure 15]. 1.3k. Anatomical atlas of the arteries and bones of the lower extremity: labeled images using 3D reconstructions and an angiographic view. Knee. [37], Penetrating injuries to the hand are a common occurrence and may result in embedment of foreign bodies [Figure 16]. Enchondromas are the second most common benign tumor of bones (after osteochondroma) and most common benign tumor of small tubular bones, as seen here in the fourth proximal phalanx of the hand. [38] A thorough history makes the diagnosis straightforward. Radiological anatomy of the shoulder, arm, elbow, forearm, wrist, hand, and fingers. 8A,B). Early radiographic changes include blurring of the soft tissue planes, followed by actual soft tissue swelling [Figure 8]. 0000009621 00000 n These phalanges are the bones of the toes (37). 0000005748 00000 n Knee. Lesions of the Distal Phalanx: Imaging Overview. Bony loss is very slow; hence, radiographic changes are often only seen in longstanding cases. 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 [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]. Forearm. Multiple enchondromatosis, such as Ollier’s disease, have a higher risk (up to 25%) of transformation into chondrosarcoma.[4]. Enchondroma is a benign, typically intramedullary tumor composed of hyaline cartilage. The proximal phalanx (P1) is the shortest (Fig. Soft tissue tumors ranging from benign to malignant lesions also cause erosions giving rise to a wide range of differential diagnoses. 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. 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��>} An enchondroma is a benign cartilaginous tumor that arises from the medullary space of the bone. 0000063033 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]. Elbow. 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]. [36] These cystic areas are typically reported as having a “honeycomb,” trabeculation pattern sparing the articular joint surface. Keratoacanthoma is normally treated conservatively, with amputation usually required in squamous cell carcinoma. When in the phalanx, lesions typically arise in the proximal metaphysis. sesamoid bones metacarpals 1 4 3 2 5 phalanges distal phalanx middle phalanx proximal phalanx head base Bony Anatomy: Mucous cysts are also very sharply defined, with a few reported cases showing internal septae. Both the Metacarpal and Phalanx have articulating surfaces; the head distally and the base proximally. In some locations it can be difficult to differentiate between enchondroma and bone infarct. Elbow. Figure 2. The fibrocartilaginous cap in subungual exostosis is hypointense on all MRI sequences, in contrast to the T2 hyperintense hyaline cartilage cap in osteochondroma. Although the signal characteristics are nonspecific, contrast enhancement can help differentiate glomus tumors from mucoid cysts and epidermoid inclusion cysts as the latter two are non-enhancing. [6] Aggressive features have not been described and no cases of malignant transformation have been reported to our knowledge in literature. The volar plate … Unlike other forms of keratoacanthoma, the subungual variant shows little or no tendency to involute over time. The ligamentous anatomy is best assessed on coronal MR and US images. 0000006470 00000 n 0000075917 00000 n 0000078136 00000 n 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�� Medial view of the first distal phalanx. The structures of … The most common benign lesion is an enchondroma while the most frequent primary malignant lesion is chondrosarcoma. ulna. Figure 1. ~�m&3�Ӵ�N���틝فHXDKZ�����{. Foot Ten–30 years may elapse before there is a substantial shortening of the digital soft tissue and underlying bones. 0000078175 00000 n The base is concave; and the head presents a trochlear surface for articulation with the second phalanx. Most enchondromas are solitary and have a very low risk of malignant transformation, especially if in the hand. Create. There is unrelated flattening and sclerosis of the second and third metatarsal heads due to healed avascular necrosis (AVN). Michael L. Richardson, M.D. On MRI, schwannomas tend to show low to intermediate T1 and high T2 signal with homogenous enhancement. The latter appears in the 2nd year and fuses with the shaft around the 15th–16th years in females and a few years later in males. 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. Bony abnormalities are typically pressure erosions, appearing as shallow, well- corticated osseous defects involving the distal phalangeal tufts adjacent to the tumor. 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 … Enchondroma is a benign, typically intramedullary tumor composed of hyaline cartilage. 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. Apart from a lucent appearance, erosions are perhaps the most common feature, rheumatoid arthritis and gout can be wrongly attributed as the underlying cause. They follow fluid signal intensity on all MRI sequences with no appreciable enhancement; differentiating this from a glomus tumor. 0000002075 00000 n The distal phalanx epiphysis ossifies slightly later than the middle and proximal phalanges; however, fusion is usually complete before that of the middle phalanx. Proper labeling of all phalangeal radiographs is important. Non- radiopaque foreign bodies may be detected by ultrasound aiding the surgeon in surgical removal.[39]. 0000025815 00000 n Lesions of the distal phalanx may arise secondary to benign or malignant pathologies and may reflect primary or secondary tumors. 0000054693 00000 n �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����'߳�. 0000004859 00000 n We provide a pictorial review of the different pathologies effecting the distal phalanx of the hand. 0000015401 00000 n Osteoid osteoma should be considered in the differential for this. The phalanges have two ossification centers: A primary ossification center and an epiphyseal center. Another differential for schwannoma confined to the distal phalanx is a digital mucous/mucoid cyst. Mycobacterium infection tends to have a predilection for the synovium and tendon sheaths compared to bone. endstream endobj 107 0 obj <>>>/Metadata 104 0 R/Outlines 93 0 R/PageLabels 101 0 R/Pages 103 0 R/Type/Catalog/ViewerPreferences<>>> endobj 108 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/Tabs/W/Thumb 94 0 R/TrimBox[0.0 0.0 581.1 822.05]/Type/Page>> endobj 109 0 obj [110 0 R 111 0 R] endobj 110 0 obj <>/Border[0 0 0]/H/N/Rect[85.7016 88.3195 154.532 79.8775]/Subtype/Link/Type/Annot>> endobj 111 0 obj <>/Border[0 0 0]/H/N/Rect[158.549 88.3195 213.401 79.8775]/Subtype/Link/Type/Annot>> endobj 112 0 obj <> endobj 113 0 obj <> endobj 114 0 obj <> endobj 115 0 obj [/ICCBased 132 0 R] endobj 116 0 obj <> endobj 117 0 obj <> endobj 118 0 obj <> endobj 119 0 obj <>stream The views needed to evaluate the third phalanx are different than those needed to evaluate the pastern. 7). Fingernail involvement presents radiographically as areas of thickening and irregularity. [ 2] When in the phalanx, lesions … In the absence of a known malignancy, the lesion may resemble osteomyelitis, septic arthritis or acute monoarticular rheumatoid arthritis. Background: Among the different breeds of horses, Asil horses with a five thousand year history have played an important role in human life. The presence of nidus on CT and florid osseous edema on MR enables to diagnose this entity [Figure 14]. 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 xref [23] Early radiographic features are nonspecific and are mainly soft tissue swelling with or without periostitis. Glomus tumors are typically solitary, but multiple lesions have been associated with type 1 neurofibromatosis. 0000009766 00000 n They occur exclusively in the distal phalanges of the fingers, typically at the tuft. CARPAL BONES. Ankle. On radiographs, enchondromas are typically seen as a well-defined central, lucent, expansile lesion without periosteal reaction or cortical disruption [Figure 1]. The metacarpal connects the proximal phalanx of the thumb to the carpal bones, through the trapeze. In more chronic cases one may see a bony sequestrum (dead bone) within an involucrum (cavity) with subsequent cloaca (opening in an involucrum allowing drainage into soft tissues) formation.[21]. 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. [5] Patients are symptomatic with fingernail displacement, pain, soft tissue swelling, and potential for soft tissue infection. 0000075395 00000 n 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. The metacarpals and phalanges can be divided into a proximal base, middle shaft, and distal head. 0000011064 00000 n The phalanges are classed as long bones. 1st proximal phalanx. Table of Contents. Knowledge of the characteristic imaging features of some specific lesions can significantly narrow the differential diagnosis and allow appropriate referral for management. [32], The most commonly reported radiographic finding apart from generalized osteopenia is subchondral bone resorption in more than one interphalangeal joint. 0000011327 00000 n AP view of the distal phalanges of the foot. [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. Typically, the history of a known primary tumor will make the diagnosis straightforward. This is typically seen as linear new bone paralleling the cortical surface with a radiolucent zone between the two. Unlike in infection, metastatic bony destruction of the digit is fairly local with relatively well preserved surrounding bone mineral density. 1st metacarpal. Start studying Radiology: Hand and finger anatomy. [30], Another characteristic radiographic feature of scleroderma is calcinosis [Figure 11]. [13] The glomus body can hypertrophy appearing as a pale pink or purple mass under the nail bed. 0000000016 00000 n 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. 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. Tuberculous dactylitis describes the painless involvement of the short tubular bones of the hands in tuberculous infection. 8D). It is these tumor-like mimics which can further complicate diagnosis. On plain radiographs, keratoacanthoma is seen a crescent- shaped soft tissue mass abutting the underlying bone. Radiographs with multiple views are advisable. [8] It presents as a painful lump under the nail bed, which can increase in size. Other signs include the “target sign,” which is an area of central low T2 signal surrounded by high T2 signal. A subungual exostosis is an osteocartilaginous tumor that typically affects the distal phalanx of the toes or fingers. Particularly for lytic lesions, there is a concern whether an underlying primary tumor or a metastatic deposit is present. Hand. Q���s�6X�FWG��? Radial side of the base of the proximal phalanx of the thumb : Recurrent … [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]. How to cite this article: Rajakulasingam R, Azzopardi C, Murphy J, Davies M, Toms A, James S, et al. 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. 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. 0000002931 00000 n We have presented a myriad of common and rare cases and have outlined some differentiating features between them on plain radiographs. This is a classic appearance of an enchondroma in a phalanx on radiographs. 0000053660 00000 n 0000076440 00000 n 0000054248 00000 n [5], On radiographs, it presents as a broad-based osseous projection arising from the distal phalanx [Figure 2]. [12], Glomus tumor represents a soft tissue hamartoma of the glomus body. [11] There may be bony erosion with an osteolytic defect due to a pressure effect rather than direct tumor invasion. The different radiological characteristics will be reviewed as well as the demographics and clinically relevant information for each lesion. Primary osteomyelitis of the distal phalanx is rare, with Staphylococcus being the most commonly involved organism. 0 Neurotropic changes result in terminal tuft resorption giving a characteristic tapered “licked candy stick” appearance [Figure 10]. 0000010166 00000 n 0000049045 00000 n [18] The most common associated feature of mucous cysts are degenerative changes at the distal interphalangeal joint. 8D) whereas the distal phalanx (P3) is the longest (Fig. 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. Pelvis. [15] Completely intraosseous glomus tumors are generally located in the terminal phalanx and encased by cortical bone appearing as smooth bony expansions with a sclerotic rim [Figure 5]. 0000063541 00000 n ��)�SЧү�+� [16] Most present as a soft tissue mass but a few intraosseous cases and a subungual location have been reported in literature. 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. 0000012576 00000 n The thumb (pollicis) does not consist of a middle phalanx, however, it does have two sesamoid bones. © 2019 Published by Scientific Scholar on behalf of Indian Journal of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, West Midlands. Phalanges. [28] Direct Mycobacterium leprae infection results in trabecular destruction giving a “honeycomb and cystic” appearance on radiographs. This webpage presents the anatomical structures found on thumb radiograph. 0000004138 00000 n 0000002792 00000 n It is by far the most common tumor involving the distal phalanx accounting for 50% of all primary bone tumors in this anatomical region. The thumb lacks a middle phalanx. Learn vocabulary, terms, and more with flashcards, games, and other study tools. 0000076998 00000 n @��\ There are no specific features to suggest schwannoma on a plain X-ray. Clinically, distal phalanx metastasis presents as a swollen and painful digit, often making it difficult to differentiate from infection. The incidence of phalangeal fractures is the highest in children aged 10 to 14 years, wh … Scleroderma is a connective tissue disorder, which can cause skin tightness and decreased elasticity in the hands. the attachment between the distal phalanx and the claw to expose the distal phalanges. We have classified these cases into different etiologies, including neoplastic and non-neoplastic lesions. [9] The latter also tends to grow quickly over a few weeks/months, whereas squamous cell carcinoma exhibits a chronic growth pattern.[10]. Saved by Lisa Holthaus. However, many of these features are non-specific. [35] Grade 1 osteosclerosis is defined as a thickening of both bony cortices by more than 1 mm. MR protocol Dedicated extremity coil Triplanar nonfat suppressed PD for anatomy [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. Exposure factors of 48–52 kV and 16–20 Forearm. �� [34] It can also represent a long-term re-ossification process following acro-osteolysis. startxref 2 X-Ray images of the hand (AP and oblique views) show the carpal bones, the bones of the hand (metacarpals) and fingers (phalanges). Ankle. Lesions are normally asymptomatic until they present with a fracture or infection. There is no calcification and lesions may be expansile. 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). %%EOF Early bony involvement is more commonly seen when there is superadded infection leading to ulceration.[27]. 165 0 obj <>stream It is more common in females usually presenting between 10 and 20 years of age.

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