Age / Sex : 66 / M

Chief complaint: Arthralgia in hand

( Clinical Hx : The patient works in the freezer and carries a cold chicken)

What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(Please submit only one answer)

Courtesy: Yeo Ju Kim, Inha University Hospital

Frostbite arthritis

Discussion

Findings:

 In hand radiographs, there are joint space narrowings, osteophytosis, subchondral scleroses, subchnodral cysts, joint destructions, and erosions are seen at right 3,4,5^th DIP joints, and left 3,4^th DIP joints and left 5^th PIP joints (more severe in left side). Soft tissue swelling is seen at DIP joints of left 3^rd and 4^th fingers. The left 5^th finger shows flexion deformity in its PIP joint, and extension deformity in its DIP joint. There are solid periosteal reactions in both radial and ulnar aspect of the left 3^rd and 4^th middle phalanx near the DIP joints. The 1^st MCP and IP joints of both thumbs are spared.

Differential Diagnosis:

 Erosive osteoarthritis /simple osteoarthritis without related to frostbite

Neuropathic arthritis

 Psoriatic arthritis

 Thermal/electrical burn

Diagnosis: 

Frostbite arthritis

Discussion:

 Frostbite

l  A thermal injury resulting in localized tissue damage due to inadequate blood circulation when the ambient temperature is below freezing.

l  The interval between the injury and presentation of symptoms: from 5 months to decades.

l  Pathophysiology

n  Unclear

n  Might be related to cellular injury and necrosis from the freezing and rewarming processes themselves or from the vascular insufficiency

l  Radiographic finding

n  Radiographic findings are caused by the insult to the hyaline cartilage and subchondral ischemic bone change (bone infarction)

n  The distal joints are more likely to be affected by the ischemic component.

n  Sparing of the thumb is characteristic, although not invariable, and can be attributed to clenching of the fist with the thumb clasped in the palm during cold exposure. 

n  Early findings (not seen in this case):

u  Osteoporosis

u  soft tissue swelling

u  loss of soft tissue especially in the tip of the digit

n  Later findings

u  Osteoporosis

u  Periostitis

u  Deformity and deviation

u  Tuft resorption of terminal phalanges (not seen in this case)

u  Large, multiple subchondral cysts, probably consecutive to bone infarcts

è  helps in differentiating frostbite arthritis from osteoarthritis.

u  Due to the cartilage damage, erosive osteoarthritis developed with joint destruction, osteophytosis, subchondral sclerosis, and joint space narrowing

n  In children (not in this case)

u  fragmention, destruction and disappearance of epipyseal center

u  prematurephyseal fusion

u  Brachydactyly

u  early osteoarthritis

u  juxta-articular cysts, periosteitis, osteoporosis

References:

1. Resnick D . Thermal and electrical injuries. In: Diagnosis of bone and joint disorders. Philadelphia: Saunders, 1995:3264–75.


2. Glick R , Parhami N. Frostbite arthritis. J Rheumatol1979;6:456–60.


3. Turner M , Smith RW. Unusual and memorable. Erosive nodal osteoarthritis after frostbite. Ann Rheum Dis1998;57:271.


4. Kemp SS, Dalinka MK, Schumacher HR. Acro-osteolysis. Etiologic and radiological considerations. JAMA1986;255:2058–61.


5. Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. J Trauma2000;48:171–8.


6.  Chan WY, Moonesamy V , Devaraj V   Osteoarthritis after cold injuries Eur J Plast Surg (2014) 37:509–512.


7. J E Kahn, O Lidove, J D Laredo, O Blétry Frostbite arthritis Ann Rheum Dis 2005;64:966-967 doi:10.1136/ard.2004.02796