Acroosteolysis

Acroosteolysis is the destruction of the distal phalanges.

Tufts preferentially affected

• Scleroderma: Look for soft tissue calcifications
• Sarcoid: Acroosteolysis can occur in 50% of patients with sarcoid of the hands. Look for small, cortical, punched-out lesions OR a permeative, lace-like pattern.
• Psoriasis: Look for erosive disease at the distal interphalangeal joints
• Neuropathy
  • Leprosy: Look for linear calcification of digital nerves
• Hyperparathyroidism: Look for subperiosteal resorption
• Thermal injury
  • Burn: Look for contractures or soft tissue calcifications.
  • Frostbite: Usually spares the thumb.
• Epidermolysis bullosa: Hereditary disorder of marked squamous epithelial fragility and blister formation, affecting the skin and mucous membranes. Patients have numerous bullous slesions, which scar after the rupturing, leading to joint contractures, and esophageal strictures.
• Hypertrophic osteoarthropathy: Look at soft tissues for clubbing of digits with flattening of nail bed angle and marked soft tissue swelling.
• Pyknodysostosis: Partial agenesis of terminal phalanges (mimics acroosteolysis). Look for open cranial sutures and fontanelles, Wormian bones, scaphocephaly, sclerotic vertebrae, fractured long bones, and stubby hands.
• Infection: Always think of osteomyelitis. This case ended up being acute osteomyelitis of the index finger (white arrow) and old osteomyelitis of the middle finger (pink arrow).

A band of lysis in middle of distal phalanx

• Polyvinyl chloride exposure
• Hajdu-Cheney syndrome: rare disorder of bone metabolism. The diagnosis is made by finding acroosteolysis with any three of the following: Wormian bones, open skull sutures, platybasia, micrognathia, mid-facial flattening, premature loss of teeth, coarse hair, and short stature.
• Infection: Always think of osteomyelitis.

References

• MSK Requisites, 3rd ed. p 331
• Wong WL, Pemberton J. The musculoskeletal manifestations of epidermolysis bullosa: an analysis of 19 cases with a review of the literature. Br J Radiol. 1992;65(774):480-4.
• Satishchandra H et al.Hajdu-Cheney syndrome. Indian Journal of Radiology and Imaging. 2008; 18(2):138-140.