Diffuse Idiopathic Skeletal Hyperostosis: Hands

We're all familiar with the spinal manifestations of diffuse idiopathic skeletal hyperostosis (DISH). Findings in the appendicular skeleton are not as well known:

• Sites of tendon and ligament attachment: Periosteal enthesophytes and dystrophic calcification can be seen.
• Joints: Para-articular osteophytes that can bridge the articulation. The bone underlying the osteophyte can be sclerotic. The involved joint can be radiographically normal, but will usually have degenerative cartilage and bony changes histologically.
• Ligaments: Ligamentous mineralization is analogous to the familiar ribbon-like calcifications seen along the anterior aspect of the vertebral bodies. Ranges from minimal involvement to involvement of the entire ligament.

In the hand, DISH can manifest as:

• Broadening and arrowheading of the distal phalangeal tufts: Can also be seen in acromegaly. Typically less marked in DISH.
• Increased cortical width of tubular bones: Can also be seen in acromegaly.
• Enlarged sesamoid bones: Can also be seen in acromegaly. Typically less marked in DISH.
• Exostoses: Metacarpal and phalangeal (orange arrow) heads, distal end of the radius (pink arrow). Here we see also one in the left scaphoid(yellow arrow). Can also be seen in acromegaly, but is typically more marked in that condition.
• Enthesopathy: At the proximal phalanges (blue arrows). Can also be seen in acromegaly, but is typically mild in that condition.
• Joint capsule bone formation: Can also be seen in acromegaly, but is typically more marked in that condition.
• Osteoarthritis and osteophyte formation: Interphalangeal joints (green arrow).

Although some of the findings can resemble those of acromegaly, patients with DISH do not have the soft tissue and cartilage hypertrophy that can be seen in acromegaly.

References

• Littlejohn GO, Urowitz MB, Smythe HA, Keystone EC. Radiographic features of the hand in diffuse idiopathic skeletal hyperostosis (DISH): comparison with normal subjects and acromegalic patients. Radiology. 1981 Sep;140(3):623-9.
• Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations. Radiology. 1975 Jun;115(3):513-24.
• Schlapbach P, Beyeler C, Gerber NJ, van der Linden S, Bürgi U, Fuchs WA, Ehrengruber H. The prevalence of palpable finger joint nodules in diffuse idiopathic skeletal hyperostosis (DISH). A controlled study. Br J Rheumatol. 1992 Aug;31(8):531-4.