Lost bones: differential diagnosis of acro-osteolysis seen by the pediatric rheumatologist

Abstract

Introduction: Acro-osteolysis is a radiographic finding which refers to bone resorption of the distal phalanges. Acro-osteolysis is associated with various conditions and its presence should prompt the clinician to search for the underlying etiology. The aim of this review is to discuss disorders with which acro-osteolysis is associated and their distinguishing features, with a focus on the pediatric population.

Methods: A targeted literature review was performed using the term "acro-osteolysis" in combination with other key terms. The primary search results were supplemented using reference citations. Articles published prior to the year 2000 were included if they described additional associations not encountered in the more recent literature.

Results: Genetic disorders (particularly primary hypertrophic osteoarthropathy and skeletal dysplasias) and rheumatic diseases (particularly psoriatic arthritis and systemic sclerosis) are the most frequently encountered conditions associated with acro-osteolysis in children. Hyperparathyroidism, neuropathy, local trauma and thermal injury, and spinal dysraphism should also be included in the differential diagnosis.

Conclusion: Although acro-osteolysis is uncommon, its presence should prompt the clinician to consider a differential diagnosis based on clinical and radiographic features.

Keywords: Acro-osteolysis; Arthritis; Genetic disorders; Hyperparathyroidism; Ischemia; Neuropathy; Pediatrics; Radiographs; Systemic sclerosis; Trauma.

Fig. 1

Frontal (a) and oblique (b) radiographs of the hands in a 14 year old male patient with primary hypertrophic osteoarthropathy demonstrate bilateral and symmetric tuft resorption and remodeling. Smooth periostitis involves the proximal phalangeal shafts (arrows). Frontal radiograph of the feet (c) shows smooth tapering of the distal tufts

Fig. 2

Frontal radiograph of the toes in a 14 year old female patient with juvenile psoriatic arthritis demonstrates focal soft tissue swelling of the fourth digit, with tapering of the distal phalanx and resorption of the distal tuft cortex

Fig. 3

Frontal radiographs of the hands in a 13 year old male patient with systemic sclerosis show tuft resorption consistent with acro-osteolysis. No soft tissue calcifications present

Fig. 4

Frontal radiograph of the left hand in a 14 year old male patient with hyperparathyroidism demonstrates acro-osteolysis (arrowheads), subperiosteal resorption at the middle phalanges (small arrows), brown tumors (large arrows) and diffuse osteopenia