A "Cool" Case of Unilateral Finger
Ari Weinreb, M.D., Ph.D.
A 44-year-old African-American man with human immunodeficiency virus (HIV) disease was referred to the rheumatology clinic for increasing pain and decreased range of motion of his right third and fourth fingers due to a suspected seronegative spondy-loarthropathy. He reported that he first noted these symptoms several years ago; however, his symptoms became increasingly severe over the past several months. He localized the pain to his right third and fourth distal interphalangeal joints, but he denied any swelling of these joints or fingers. He was unable to fully flex these fingers, resulting in decreased function of his right hand. He had a history of chronic low back pain associated with an L5-S1 herniated disc that developed after a motor vehicle accident several years prior. His back pain did not improve with activity. He denied morning stiffness or any other joint or soft tissue pain, oral ulcers, conjunctivitis or other eye inflammation, dysuria, penile rashes or discharges, other rashes, or history of diarrheal illnesses. He also denied any history of fractures or joint dislocations involving the affected fingers. There was no family history of psoriasis or arthritis.
His examination was significant for Heberden's nodes involving the right third and fourth distal interpha-langeal joints, associated with tenderness to palpation and decreased range of motion to flexion. There was no swelling of these joints or of the fingers. The remainder of the examination was significant for the absence any other joint tenderness or synovitis, conjuctival/scleral injection, or rashes. A radiograph of the right fingers was negative for any soft tissue swelling or acute osseous injury, but it revealed joint space narrowing and small subchondral cystic changes consistent with osteoarthritis involving the third through fifth distal interphalangeal joints. A lumbosacral radiograph reported normal-appearing intervertebral disc spaces and sacroiliac joints.
Upon further discussion with the patient, he recalled that he developed frostbite of both hands several years prior while working in Alaska as a mechanic in the United States Navy. Although he had bilateral involvement of his hands by the frostbite, his right hand was more severely affected with extensive skin blistering and loss of the fingernails.
Given his past frostbite injury and the findings on the physical and radiological examinations, the patient was given a diagnosis of frostbite osteoarthritis.
The presentation of unilateral osteoarthritis involving several distal interphalangeal joints in a relatively young patient, as in this case, is atypical for primary osteoarthritis. The patient was referred by the HIV Clinic out of concern of a possible spondy-loarthropathy given the presence of an oligoarticular arthritis in the setting of HIV positivity and a history of low back pain. Several rheumatologic diseases and syndromes have been associated with HIV disease. Specifically with respect to arthritis, several different presentations have been characterized. These include arthralgias, the self-limited painful joint syndrome (lasting <24 hours), a self-limited seronegative oligoarticular asymmetric arthritis (lasting <6 weeks), a Reiter's/reactive arthritis, psoriasis/psoriatic arthritis (tends to occur in advanced HIV disease), and avas-cular necrosis.1 The examination findings, particu-larly the distal interphalangeal involvement, the absence of joint swelling, the absence of digital swelling, and the presence of Heberden's nodes was consistent with osteoarthritis and made an HIV-asso-ciated arthritis unlikely. The radiographic studies of the fingers supported the diagnosis of osteoarthritis. Moreover, the patient's back pain history was non-inflammatory in nature (not associated with stiffness or activity-associated improvement), with the clinical absence of sacroiliitis supported by the normal radi-ographic appearance of the sacroiliac joints.
The presence of a unilateral osteoarthritis usually indicates the presence of a secondary form of osteoarthritis. The more common causes of secondary arthritis include trauma, calcium pyrophos-phate deposition disease (pseudogout), joint damage due to rheumatoid arthritis or septic arthritis, avas-cular necrosis, and Charcot arthropathy. The patient's clinical history and exam findings made these secondary causes of osteoarthritis unlikely. However, the patient's history of frostbite prior to the onset of his finger joint symptoms and the absence of any other obvious cause of secondary osteoarthritis is consistent with the diagnosis of frostbite arthritis.
Acute frostbite can vary in severity, ranging from skin erythema to full thickness skin loss. Severe involvement can result in bone necrosis and tissue loss.2 The secondary arthritis that results from a frostbite injury tends to involve the distal joints in the involved extremity (in the hands, the distal interphalangeal joints affected more commonly that the proximal interphalangeal joints). The distribution can be both symmetric and asymmetric. Although in this case, the development of arthritis was associated with the more severe frostbite of the right hand, frostbite arthritis can develop with minimal cold injury. The symptoms can vary from mild joint pain and stiffness to intermittent episodes of severe joint pain.2 An interesting and clinically important feature of frostbite arthritis concerns the time to onset of the arthritis following the episode of frostbite. The time to both the onset of symptoms of the arthritis and the development of the associated radiologic changes varies widely. Changes have been noted as early as 3 to 5 or 6 months after an episode of frostbite.3,4,5 There have also been reports of symptoms developing 7 to 10 years following an episode of frostbite.2,6,7 The variability in onset of symptoms is further demonstrated in a case in which a 22-year-old patient developed distal and proximal interphalangeal joint deformities of his right hand associated with the inability to make a fist within a few months following an episode of severe frostbite. He was otherwise symptom-free for 35 years, after which he developed frequent episodes of erythema, swelling, and severe pain in these joints associated with allodynia of the involved fingers.8 In addition to arthritis, other cold-induced changes that may contribute to musculoskeletal symptoms include increased cold-sensitivity, dysesthesia, sensory loss, symptoms of vasomotor instability, and hyperhidrosis.9,10
Early radiologic change following frostbite is charac-terized by demineralization. The later bone and joint changes that characterize frostbite arthritis in adults consist of articular surface irregularities, joint space narrowing, punched-out juxtaarticular and subchon-dral bone irregularities, small subchondral cystic lucencies, subchondral sclerosis, and, less commonly, osteophytes and ankylosis.4,11,12 Frostbite in children and adolescents in which there is still active bone growth can result in abnormal growth of the epiphyses with phalangeal malformation and premature closure of the epiphyses with phalangeal shortening.11 The mechanism of tissue damage in frostbite consists of intracellular dehydration due to ice crystal formation, exacerbated by repeated freeze/thaw cycles, followed by thrombosis and tissue ischemia.10 However, the mechanism contributing to the cartilage and bone damage present in frostbite arthritis remains unclear, as most studies of freezing damage have not examined the cartilage or bone. The mechanism of cartilage and bone damage may differ from that of soft tissue damage as arthritis has developed following only mild soft tissue damage. Moreover, it has been suggested that as chondrocytes are primarily glycolytic in their metabolism, they would be less susceptible to tissue ischemia.11
It is important for practitioners to be aware of frost-bite arthritis. Its asymmetrical presentation with asso-ciated severe pain in some cases could be confused with other forms of asymmetric oligoarticular arthritis, such as the seronegative spondy-loarthropathy initially suspected in the patient presented in this case report. The diagnosis may also be complicated by the long latency period of up to several years from the initial frostbite to the develop-ment of the arthritis. Although the risk of frostbite is increased in individuals who reside in colder areas, the increase in winter sports and activities by individ-uals from warmer climates should not be forgotten. A cold exposure and frostbite history should be obtained in any patient presenting with a unilateral osteoarthritis, particularly if there is no other history of trauma.
- Reveille JD. Rheumatic manifestations of human immunodeficiency virus infection. In: Harris ED, Budd RC, Genovese MC, Firestein, Sargent JS, Sledge CB, editors. Kelley's Textbook of Rheumatology, 7th ed. Philadelphia (PA):Elsevier Saunders; 2005. p.1661-1664.
- McKendry RJ. Frostbite arthritis. Can Med Assoc J. 1981 Nov;125(10):1128-1130.
- Turner M, Smith RW. Unusual and memorable. Erosive nodal osteoarthritis after frostbite. Ann Rheum Dis. 1998 May;57(5):271.
- Blair JR, Schatzki R, Orr KD. Sequelae to cold injury in one hundred patients, follow-up study of four years after occurrence of cold injury. JAMA. 1957 Apr;163:1203-1208.
- Ellis R, Short JG, Simonds BD. Unilateral osteoarthritis of the distal interphalangeal joints following frostbite. Radiology. 1969 Oct;93:857-858.
- Schumacher HR. Unilateral osteoarthritis of the hand. JAMA. 1965 Jan;191:246-247.
- Schwenke R. Case report on osteoarthropathy following frostbite. Z Gesamte Inn Med. 1984 Dec;39(23):592-595.
- Glick R, Parhami N. Frostbite arthritis. J Rheumatol. 1979 Jul;6(4):456-460.
- Jarrett F. Frostbite: current concepts of pathogenesis and treatment. Rev Surg. 1974 Mar;31(2):71-74.
- Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. J Trauma. 2000 Jan;48(1):171-178.
- Carrera GF, Kozin F, McCarty DJ. Arthritis after frostbite injury in children. Arthritis Rheum. 1979 Oct;22(10):1082-1087.
- Vinson KA, Schatzki R. Roentgenologic bone changes encountered in frostbite, Korea 1950-51. Radiology. 1954 Nov;63(5):685-695.
Originally submitted on May 27, 2005