Hand CASE 7
CASE 7
A retired, 80-year-old, Caucasian, male obstetrician is asked to see you for a painful and swollen fingertip. Three days ago, he noticed the onset of swelling and this was followed by the development of a fluctuant swelling over the dorsal aspect of the DIP joint. His primary care doctor diagnosed him with an infection and placed him on oral antibiotics. He continues to have increasing pain. There is some redness, but he denies running any fever. Of note, he is otherwise healthy apart from being hypertensive and taking hydrochlorothiazide. He denies having any other past medical history. The clinical appearance and radiograph are shown in Figure 4–6A and B.
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Figure 4–6 A–B
The mostly likely diagnosis is:
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Acute paronychia
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Pyoarthrosis of the DIP joint
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Acute tophaceous gout
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Cellulitis
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Cutaneous wart
Discussion
The correct answer is (C). This appearance is typical of acute tophaceous gout in a patient in this age group. There is increasing evidence to show that acute tophaceous gout of the distal interphalangeal (DIP) joint is the first form of presentation in the elderly. This is typically seen in patients over the age of 70, with a pre-existing arthritic DIP joint, and who happen to be on diuretics. Gout is a disorder of purine
metabolism in which there is deposition of monosodium biurate crystals in areas which are affected by arthritis. The DIP joint is one of the most commonly affected joints in the hand and therefore appears to be particularly prone to developing symptoms of acute tophaceous gout.
The most appropriate management at this stage would be to do which of the following?
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Stop oral antibiotics and switch to intravenous antibiotics
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Starting the patient on oral antigout medication such as allopurinol
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Drainage of acute tophaceous gout, confirmation of the diagnosis, and starting the patient on acute gout medication such as colchicine
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Emergent irrigation, excision, and debridement in the operating room with fusion of the DIP joint
Discussion
The correct answer is (C). Although the appearance is fairly typical and may be considered classic, it is important to confirm the diagnosis. Inflammatory markers can be elevated in gout and the uric acid levels are not always elevated. It is therefore important to acquire a fluid sample and examine it under the microscope to see the needle-shaped, negatively birefringent, monosodium biurate crystals. The technique for asipration described by Mudgal involves the placement of two large bore needles proximal to the tophaceous area without disturbing the thin, soft tissue envelope over the tophaceous area. The large bore needles allow aspiration of the material and allow the soft tissue envelope to collapse on itself. The DIP joint is then held splinted and wrapped so as to allow egress of the material. The patient is encouraged to begin soaks on a daily basis. The holes made by the needles usually don’t close for a couple days, and the saline soaks allow the material to be washed out. Gout crystals being water soluble helps in reduction of the tophus burden. After this has been done, the patient’s joint is splinted and edema control is achieved with the help of elasticated wraps.
The fluid shows the presence of crystals confirming the diagnosis of gout. The patient is started on medication for his gout including colchicine and allopurinol. Eight weeks later, the patient comes in to see you, and the appearance of the digit is much better than before. However, he continues to have a painful, unstable joint, and he wonders if he can have something done so that he may be able to use the finger in a more effective fashion.
The next step in management would be which of the following?
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QuickCast application for 8 weeks
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Orthoplast splint application for the rest of his life
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No active treatment required since the patient is not working
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Arthrodesis of the DIP joint
Discussion
The correct answer is (D). The patient, albeit retired, is active and functioning. He has a painful and unstable DIP joint. Radiographs demonstrate that this joint is an extremely arthritic joint. Therefore, this joint is a nonsalvageable joint and is unlikely to have any motion that is meaningful. All these criteria make him an excellent candidate for DIP arthrodesis. Multiple techniques have been described for DIP arthrodesis including the use of wires, steel wires, and headless screws. DIP arthrodesis can be done by open techniques or by percutaneous techniques. In situations where there is no obvious deformity but there is instability and the joint is collinear, percutaneous arthrodesis is indicated. A headless screw is placed from the tip of the distal phalanx, across the DIP joint and into the medullary canal of the middle phalanx. Excellent compression is generated and, since the joint has no meaningful articular cartilage, these patients go on to develop arthrodesis over the course of the next 3 to 4 months. Percutaneous arthrodesis is a well-described technique and is suitable only for patients who have an extremely arthritic and/or painful joint without a static deformity. If the deformity of the DIP joint is fixed and noncorrectable, these patients are not suitable for percutaneous arthrodesis and need to have a formal open arthrodesis, whereby the joint surfaces are resected, the joint is realigned, and then a fusion is performed.
Objectives: Did you learn...?
Distinguish the clinical presentation of acute tophaceous gout? Initially treat acute tophaceous gout?
Determine definitive treatment?