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A 60-year-old pianist with pain and swelling of the left long finger

A los 60 años de edad, el pianista dominante de la derecha presenta a la clínica con quejas de dolor y la hinchazón de su largo dedo izquierdo articulación metacarpofalángica. Informó síntomas leves durante los últimos 15 años, pero el dolor había empeorado significativamente durante el último año y medio. También informó de una leve molestia en su metacarpofalángica índice izquierdo y pequeñas articulaciones metacarpofalángicas derechas. No había antecedentes de trauma o de otro evento desencadenante. 

Declaró su dolor era peor de noche, con una mínima rigidez matinal. Actividades de las actividades de la vida cotidiana y de recreación, tales como jardinería, exacerban el dolor. Debido a la incomodidad, ella era incapaz de tocar el piano. Señaló los cambios de color de su índice y dedos largos con tiempo frío. Fue tratada inicialmente con AINE y una inyección de corticosteroides de la larga metacarpofalángica (MCF), que alivia el dolor por varias semanas. Una nueva inyección proporcionado ningún alivio y ella tenía poca tolerancia con el uso crónico de AINE.

A 60-year-old right-hand dominant pianist presented to clinic with complaints of pain and swelling of her left long finger metacarpophalangeal joint. She reported mild symptoms during the past 15 years, but the pain had significantly worsened during the last year and a half. She also reported mild discomfort in her left index metacarpophalangeal and right small metacarpophalangeal joints. There was no history of trauma or other inciting event.

She stated her pain was worse at night, with minimal morning stiffness. Activities of daily living and recreational activities, such as gardening, exacerbated her pain. Due to discomfort, she was unable to play the piano. She noted color changes of her index and long fingers with cold weather. She was initially treated with NSAIDs and a corticosteroid injection of the long metacarpophalangeal (MCP) joint, which alleviated her pain for several weeks. A repeat injection provided no relief and she had poor tolerance to chronic NSAID use.

Figure 1. Physical examination of the left
hand was notable for shortening of the
long finger (solid arrow) and prominent
swelling of the long meta-carpophalengeal
joint (dotted arrow).

Images: Kho JY and Shah AS

Her past medical history was unremarkable, and her family history was negative for inflammatory or rheumatologic disease. There was no history of oral or parenteral steroid use. She smoked roughly a pack of cigarettes a week and occasionally consumed wine with dinner.

Physical examination and imaging

Physical exam was notable for prominent swelling, erythema and tenderness to palpation of the left long MCP joint. Inspection revealed shortening of the long finger ray (Figure 1). The interphalangeal joints were not affected, and she had full range of motion of the wrist and other digits. A neurovascular exam of the patient was unremarkable. Erythrocyte sedimentation rate (ESR), C-reactive protein and immunological test results were within normal limits.

Anteroposterior (AP), oblique and lateral radiographs of the hand showed destructive changes of the long metacarpal head with flattening, irregularity and shortening (Figures 2a and 2b). The surrounding MCP joints were not involved.

Figure 2. AP radiograph of both hands (a) and oblique radiograph of the left hand demonstrated flattening and shortening of the long metacarpal head with cystic and sclerotic changes (b). Surrounding joints were not involved. Incidental findings included two foreign bodies in the index and long fingertips.

MRI without contrast demonstrated a low T1, high T2 signal in the long metacarpal head with capsular distension. There was also irregularity of the long metacarpal head with mild surrounding enhancement and signs of edema extending into the diaphysis. No imaging abnormalities were detected in the left index and right small MCP joints.

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