Skeletal Radiol DOI 10.1007/s00256-014-1908-4
CASE REPORT
Acute calcific tendinitis of the flexor pollicis longus in an 8-year-old boy Arvin Kheterpal & Adam Zoga & Kristen McClure
Received: 4 January 2014 / Revised: 7 April 2014 / Accepted: 5 May 2014 # ISS 2014
Abstract Calcific tendinitis is a common source of musculoskeletal pain in adults; however, it is rarely encountered in children. Calcific tendinitis is the most commonly encountered manifestation of hydroxyapatite deposition disease, in which calcium hydroxyapatite crystal deposition occurs in tendons. It may cause acute or chronic pain, or may be entirely asymptomatic. We describe a case of acute calcific tendinitis of the flexor pollicis longus tendon in an 8-yearold boy, who initially presented to our department for workup of a mass felt along the volar aspect of the right wrist.
the clinical presentation may often overlap with trauma, septic arthritis, tenosynovitis, or even a soft tissue mass, making the diagnosis challenging [5, 10, 18]. Imaging studies, however, can help clinch the diagnosis and more importantly, prevent the misdiagnosis of the more ominous aforementioned conditions. In this case report, we describe the clinical presentation and imaging findings of calcific tendinitis of the flexor pollicis longus in an 8-year-old boy, who initially presented for workup of a mass felt along the volar aspect of the right wrist.
Keywords Calcific tendinitis . Calcium hydroxyapatite . Flexor pollicis longus . Pediatrics
Case report
Introduction Calcific tendinitis is a widely encountered and welldescribed, often painful condition manifested by calcium hydroxyapatite deposition into tendons. In adults, it is most frequently encountered in the shoulder, where calcific deposition into the rotator cuff tendons may cause acute pain, chronic pain, or no pain at all [9]. However, calcium hydroxyapatite deposition may also occur in children, albeit much less frequently, and it may involve less commonly encountered tendons. Patients may present with either acute or chronic pain, thus the clinical presentation can be confusing. Furthermore, patients may present with a low-grade fever, erythema, decreased range of motion, or a palpable mass [18]. As a result, A. Kheterpal (*) : A. Zoga : K. McClure Musculoskeletal Radiology Division, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA e-mail: [email protected]
An 8-year-old boy with no past medical history presented to his pediatrician with acute onset of right wrist pain and swelling. The patient denied any history of recent trauma. On physical exam, the patient was afebrile with focal soft tissue swelling over the right wrist, raising concern for a soft tissue mass. As a result, the patient was referred to our department for sonographic evaluation. Ultrasound of the right wrist was performed, which showed a complex area of calcification intimately associated with the flexor pollicis longus tendon (Fig. 1). On color Doppler, there was surrounding hyperemia, but no internal vascularity to suggest a soft tissue component (Fig. 2). Radiographs of the right wrist were subsequently obtained, which confirmed fairly dense calcifications along the volar aspect of the wrist with overlying soft tissue swelling (Fig. 3a, c). Although the radiographic findings were consistent with calcific tendinitis, given the unusually young age of the patient, an MRI was performed to exclude a partially calcified mass. The MRI showed interstitial tearing of the flexor pollicis longus tendon with calcification that had ruptured into the adjacent soft tissues, confirming the diagnosis of calcific tendinitis (Fig. 4a, c).
Skeletal Radiol Fig. 1 Static ultrasound image of the right wrist in long axis shows an irregularly shaped, shadowing soft tissue calcification (large arrow) adjacent to the flexor pollicis longus (small arrow). There is associated tenosynovitis and soft tissue edema
Upon further questioning, specifically about repetitive activities, the parents noted that the patient was an avid video game player, who typically played video games every day for several hours, including the night prior to presentation. The patient was subsequently managed conservatively with rest and pain medicine as needed, with gradual resolution of symptoms over the next month. The patient’s pain and swelling completely resolved, thus no follow-up imaging was obtained.
Discussion Hydroxyapatite deposition disease encompasses a broad spectrum of musculoskeletal pathology including calcific tendinitis, other periarticular and intraarticular deposits, and hydroxyapatite-induced destructive arthropathies. Calcific tendinitis is the most commonly encountered manifestation of hydroxyapatite deposition disease. The condition is typically monoarticular and most commonly affects the rotator cuff tendons in adults in the fourth to sixth decades. However, other anatomic locations of calcific tendinitis have been described, including tendons about the hip, spine, elbow, wrist, and knee [1, 8, 9, 12].
Fig. 2 Static ultrasound image of the right wrist in long axis with color Doppler shows hyperemia surrounding the calcification (large arrow), but no internal vascularity. Hyperemia also surrounds the flexor pollicis longus tendon (small arrow)
Accurate diagnosis of calcific tendinitis is generally made when clinical symptoms provoke further investigation, including radiologic evaluation and laboratory studies. When symptomatic, there may be acute or chronic pain, decreased range of motion, erythema, periarticular edema, and tenderness to palpation. The patient may also have a low-grade fever, and a mildly elevated white blood cell count, erythrocyte sedimentation rate, or C-reactive protein during the acute presentation [12, 15, 17]. The diagnosis of hydroxyapatite deposition can be made with multiple imaging modalities, either alone, or in combination, as was done in this case. Radiographs may show poorly defined cloud-like densities (usually periarticular in location), typical of a more recent deposit, or they may show well-defined opaque densities, typical of an older deposit [4]. Although evolution and/or resorption of the hydroxyapatite crystals is known to occur, no follow-up radiographs of this patient were obtained due to complete resolution of symptoms with conservative treatment. Sonographically, the identification of a hyperechoic shadowing focus intimately associated with a tendon is typical of calcium hydroxyapatite deposition. With acute presentations, there may be associated tenosynovitis and/or periarticular edema. With longstanding disease, there may associated cortical erosions, which although
Skeletal Radiol
Fig. 3
Lateral (a), AP (b), and oblique (c) radiographs of the right wrist show a fairly dense ovoid calcification (arrows) over the volar and radial aspect of the wrist. The osseous structures are normal
uncommon, can be well demonstrated by ultrasound. MRI can also be useful, as the calcification, if observed, can cause susceptibility artifact, which is best visualized on a gradient echo sequence [4]. Additional MRI findings may include soft tissue and bone marrow edema, with or without cortical erosion, as well as ill-defined hypointensity on all sequences in the region of the tendinous calcification. In the case presented here, MRI was useful in excluding a soft tissue mass. Furthermore, the MRI provided additional anatomic information, showing rupture of the calcification from the flexor pollicis longus tendon sheath into the surrounding soft tissues with extensive surrounding subcutaneous edema, a feature which some postulate is responsible for acute presentations of pain in calcific tendinitis [8, 18]. Conservative treatment options of calcific tendinitis include nonsteroidal anti-inflammatory drugs, periarticular steroid injections, physical therapy, therapeutic ultrasound, ultrasound-guided lavage, and extracorporeal shock wave therapy [3, 11, 17]. When patients fail to clinically improve following nonsurgical management, surgical treatment options are offered, including arthroscopic and open debridement [14]. However, most patients improve with conservative treatment as did our patient. Although the pathophysiology of calcium hydroxyapatite crystal deposition into tendons is not well delineated, several theories and proposed risk factors exist. One theory suggests that cartilaginous metaplasia secondary to hypoxia in the setting of tendinosis may ultimately lead to calcification [4, 19]. Other theories have raised the possibility of an underlying metabolic disorder, such as renal failure [8]. The metabolic and genetic influences of hydroxyapatite deposition disease have not yet been fully investigated. Overuse/repetitive activity is also thought to be a main contributor in the development of calcium deposition [18]. Ultimately, however, the predisposing risk factors and pathophysiology of calcium hydroxyapatite deposition remain controversial [8]. While it is impossible to definitively identify the underlying cause of calcium hydroxyapatite deposition in the patient presented here, his history of frequent video gaming and curious involvement of his flexor pollicis longus tendon raise the possibility of overuse/repetitive activity as an etiology, given that most video game controllers are predominantly thumb and index finger operated. However, other confounding reasons for the development of calcific deposits in the flexor pollicis longus tendon in this patient are possible. Acute calcific tendinitis uncommonly affects children, and is usually not considered clinically. Nevertheless, there are several case reports of calcific tendinitis in children involving tendons in the hands or wrists, similar to this case [2, 6, 7, 13].
Skeletal Radiol
Fig. 4
Fat-saturated T2 sagittal (a), fat-saturated T2 axial (b), and T1 axial (c) MRI images show interstitial tearing of the flexor pollicis longus tendon (small arrows) with rupture of the calcification (large arrows) into the adjacent volar soft tissues. There is tenosynovitis and extensive surrounding subcutaneous edema
Fong describes a case of calcific tendinitis of the supraspinatus tendon in a 7-year-old boy and Sakamoto and colleagues describe calcific tendinitis at the biceps brachii insertion in a 3-year-old boy; although these locations are much less common in children [5, 16]. Fortunately, the aforementioned imaging findings are similar, regardless of the age of the patient or location of the calcium deposit. Although the clinical presentation of acute calcific tendinitis can overlap with trauma, infection, or a soft tissue mass as in this case, a thorough history and physical exam in combination with imaging studies can clinch the diagnosis in atypical presentations. Most importantly, recognizing this entity in children will prevent the misdiagnosis of more ominous conditions. Conflict of interest The authors declare that they have no conflicts of interest to report.
References 1. Bonavita JA, Dalinka MK, Schumacher HR. Hydroxyapatite deposition disease. Radiology. 1980;134:621–5. 2. Carrol RE, Seitz WH, Putnam MD. Acute calcium deposit in the hand of an 11-year-old girl. J Ped Ortho. 1985;5:468–70. 3. Chow HY, Recht MP, Schils J, Calabrese LH. Acute calcific tendinitis of the hip: case report with magnetic resonance imaging findings. Arthritis Rheum. 1997;40(5):974–7. 4. Farpour F, Maasumi K, Tehranzadeh J. Imaging of crystal deposition diseases. Applied Radiology Online. 2012;41(8):18–25. 5. Fong CM. Calcific tendinitis of the supraspinatus tendon in a 7year-old boy: diagnostic challenges. Hong Kong Med J. 2011;17: 414–6. 6. Hakozaki M, Iwabuchi M, Konno S, Kikuchi S. Acute calcific tendinitis of the thumb in a child: a case report. Clin Rheumatol. 2007;26:841–4. 7. Hansen U, Battista V. Pediatric trigger finger from calcific tendonitis. J Hand Surg. 2007;32A:1558–9. 8. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics. 1990;10:1031–48. 9. Holt PD, Keats T. Calcific tendinitis: a review of the usual and unusual. Skeletal Radiol. 1993;22:1–9. 10. Hulse N, Kumar A. Calcific tendinitis: an infrequent and misdiagnosed cause of acute wrist pain—a case report. Indian J Ortho. 2006;40(1):57. 11. Hurt G, Baker CL. Calcific tendinitis of the shoulder. Orthop Clin N Am. 2003;34:567–75. 12. Kraemer EJ, El-Khoury GY. Atypical calcific tendinitis with cortical erosions. Skeletal Radiol. 2000;29:690–6. 13. Millon SJ, Bush DC, Harrington TM. Acute calcific tendinitis in a child: a case report. J Hand Surg [Am]. 1993;18:592–3. 14. Ryan LM, Rosenthal AK. Metabolism of extracellular pyrophosphate. Curr Opin Rheumatol. 2003;15:311–4.
Skeletal Radiol 15. Sakai T, Shimaoka Y, Sugimoto M, Koizumi T. Acute calcific tendinitis of the gluteus medius: a case report with serial magnetic resonance imaging findings. J Orothopaedic Science. 2004;9:404–7. 16. Sakamato K, Kozuki K. Calcific tendinitis at the biceps brachii insertion of a child: a case report. J Shoulder Elbow Surg. 2002;11: 88–91.
17. Speed CA, Hazleman BL. Calcific tendinitis of the shoulder. NEJM. 1999;340(20):1582–4. 18. Torbati S, Daniel B, Geiderman JM. Acute calcific tendinitis of the wrist. J Emerg Med. 2013;44(2):352–4. 19. Uhthoff HK. Calcifying tendinitis, an active cell-mediated calcification. Virchows Archiv A 3. 1975;366(1):51–8.
CASE REPORT
Acute calcific tendinitis of the flexor pollicis longus in an 8-year-old boy Arvin Kheterpal & Adam Zoga & Kristen McClure
Received: 4 January 2014 / Revised: 7 April 2014 / Accepted: 5 May 2014 # ISS 2014
Abstract Calcific tendinitis is a common source of musculoskeletal pain in adults; however, it is rarely encountered in children. Calcific tendinitis is the most commonly encountered manifestation of hydroxyapatite deposition disease, in which calcium hydroxyapatite crystal deposition occurs in tendons. It may cause acute or chronic pain, or may be entirely asymptomatic. We describe a case of acute calcific tendinitis of the flexor pollicis longus tendon in an 8-yearold boy, who initially presented to our department for workup of a mass felt along the volar aspect of the right wrist.
the clinical presentation may often overlap with trauma, septic arthritis, tenosynovitis, or even a soft tissue mass, making the diagnosis challenging [5, 10, 18]. Imaging studies, however, can help clinch the diagnosis and more importantly, prevent the misdiagnosis of the more ominous aforementioned conditions. In this case report, we describe the clinical presentation and imaging findings of calcific tendinitis of the flexor pollicis longus in an 8-year-old boy, who initially presented for workup of a mass felt along the volar aspect of the right wrist.
Keywords Calcific tendinitis . Calcium hydroxyapatite . Flexor pollicis longus . Pediatrics
Case report
Introduction Calcific tendinitis is a widely encountered and welldescribed, often painful condition manifested by calcium hydroxyapatite deposition into tendons. In adults, it is most frequently encountered in the shoulder, where calcific deposition into the rotator cuff tendons may cause acute pain, chronic pain, or no pain at all [9]. However, calcium hydroxyapatite deposition may also occur in children, albeit much less frequently, and it may involve less commonly encountered tendons. Patients may present with either acute or chronic pain, thus the clinical presentation can be confusing. Furthermore, patients may present with a low-grade fever, erythema, decreased range of motion, or a palpable mass [18]. As a result, A. Kheterpal (*) : A. Zoga : K. McClure Musculoskeletal Radiology Division, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA e-mail: [email protected]
An 8-year-old boy with no past medical history presented to his pediatrician with acute onset of right wrist pain and swelling. The patient denied any history of recent trauma. On physical exam, the patient was afebrile with focal soft tissue swelling over the right wrist, raising concern for a soft tissue mass. As a result, the patient was referred to our department for sonographic evaluation. Ultrasound of the right wrist was performed, which showed a complex area of calcification intimately associated with the flexor pollicis longus tendon (Fig. 1). On color Doppler, there was surrounding hyperemia, but no internal vascularity to suggest a soft tissue component (Fig. 2). Radiographs of the right wrist were subsequently obtained, which confirmed fairly dense calcifications along the volar aspect of the wrist with overlying soft tissue swelling (Fig. 3a, c). Although the radiographic findings were consistent with calcific tendinitis, given the unusually young age of the patient, an MRI was performed to exclude a partially calcified mass. The MRI showed interstitial tearing of the flexor pollicis longus tendon with calcification that had ruptured into the adjacent soft tissues, confirming the diagnosis of calcific tendinitis (Fig. 4a, c).
Skeletal Radiol Fig. 1 Static ultrasound image of the right wrist in long axis shows an irregularly shaped, shadowing soft tissue calcification (large arrow) adjacent to the flexor pollicis longus (small arrow). There is associated tenosynovitis and soft tissue edema
Upon further questioning, specifically about repetitive activities, the parents noted that the patient was an avid video game player, who typically played video games every day for several hours, including the night prior to presentation. The patient was subsequently managed conservatively with rest and pain medicine as needed, with gradual resolution of symptoms over the next month. The patient’s pain and swelling completely resolved, thus no follow-up imaging was obtained.
Discussion Hydroxyapatite deposition disease encompasses a broad spectrum of musculoskeletal pathology including calcific tendinitis, other periarticular and intraarticular deposits, and hydroxyapatite-induced destructive arthropathies. Calcific tendinitis is the most commonly encountered manifestation of hydroxyapatite deposition disease. The condition is typically monoarticular and most commonly affects the rotator cuff tendons in adults in the fourth to sixth decades. However, other anatomic locations of calcific tendinitis have been described, including tendons about the hip, spine, elbow, wrist, and knee [1, 8, 9, 12].
Fig. 2 Static ultrasound image of the right wrist in long axis with color Doppler shows hyperemia surrounding the calcification (large arrow), but no internal vascularity. Hyperemia also surrounds the flexor pollicis longus tendon (small arrow)
Accurate diagnosis of calcific tendinitis is generally made when clinical symptoms provoke further investigation, including radiologic evaluation and laboratory studies. When symptomatic, there may be acute or chronic pain, decreased range of motion, erythema, periarticular edema, and tenderness to palpation. The patient may also have a low-grade fever, and a mildly elevated white blood cell count, erythrocyte sedimentation rate, or C-reactive protein during the acute presentation [12, 15, 17]. The diagnosis of hydroxyapatite deposition can be made with multiple imaging modalities, either alone, or in combination, as was done in this case. Radiographs may show poorly defined cloud-like densities (usually periarticular in location), typical of a more recent deposit, or they may show well-defined opaque densities, typical of an older deposit [4]. Although evolution and/or resorption of the hydroxyapatite crystals is known to occur, no follow-up radiographs of this patient were obtained due to complete resolution of symptoms with conservative treatment. Sonographically, the identification of a hyperechoic shadowing focus intimately associated with a tendon is typical of calcium hydroxyapatite deposition. With acute presentations, there may be associated tenosynovitis and/or periarticular edema. With longstanding disease, there may associated cortical erosions, which although
Skeletal Radiol
Fig. 3
Lateral (a), AP (b), and oblique (c) radiographs of the right wrist show a fairly dense ovoid calcification (arrows) over the volar and radial aspect of the wrist. The osseous structures are normal
uncommon, can be well demonstrated by ultrasound. MRI can also be useful, as the calcification, if observed, can cause susceptibility artifact, which is best visualized on a gradient echo sequence [4]. Additional MRI findings may include soft tissue and bone marrow edema, with or without cortical erosion, as well as ill-defined hypointensity on all sequences in the region of the tendinous calcification. In the case presented here, MRI was useful in excluding a soft tissue mass. Furthermore, the MRI provided additional anatomic information, showing rupture of the calcification from the flexor pollicis longus tendon sheath into the surrounding soft tissues with extensive surrounding subcutaneous edema, a feature which some postulate is responsible for acute presentations of pain in calcific tendinitis [8, 18]. Conservative treatment options of calcific tendinitis include nonsteroidal anti-inflammatory drugs, periarticular steroid injections, physical therapy, therapeutic ultrasound, ultrasound-guided lavage, and extracorporeal shock wave therapy [3, 11, 17]. When patients fail to clinically improve following nonsurgical management, surgical treatment options are offered, including arthroscopic and open debridement [14]. However, most patients improve with conservative treatment as did our patient. Although the pathophysiology of calcium hydroxyapatite crystal deposition into tendons is not well delineated, several theories and proposed risk factors exist. One theory suggests that cartilaginous metaplasia secondary to hypoxia in the setting of tendinosis may ultimately lead to calcification [4, 19]. Other theories have raised the possibility of an underlying metabolic disorder, such as renal failure [8]. The metabolic and genetic influences of hydroxyapatite deposition disease have not yet been fully investigated. Overuse/repetitive activity is also thought to be a main contributor in the development of calcium deposition [18]. Ultimately, however, the predisposing risk factors and pathophysiology of calcium hydroxyapatite deposition remain controversial [8]. While it is impossible to definitively identify the underlying cause of calcium hydroxyapatite deposition in the patient presented here, his history of frequent video gaming and curious involvement of his flexor pollicis longus tendon raise the possibility of overuse/repetitive activity as an etiology, given that most video game controllers are predominantly thumb and index finger operated. However, other confounding reasons for the development of calcific deposits in the flexor pollicis longus tendon in this patient are possible. Acute calcific tendinitis uncommonly affects children, and is usually not considered clinically. Nevertheless, there are several case reports of calcific tendinitis in children involving tendons in the hands or wrists, similar to this case [2, 6, 7, 13].
Skeletal Radiol
Fig. 4
Fat-saturated T2 sagittal (a), fat-saturated T2 axial (b), and T1 axial (c) MRI images show interstitial tearing of the flexor pollicis longus tendon (small arrows) with rupture of the calcification (large arrows) into the adjacent volar soft tissues. There is tenosynovitis and extensive surrounding subcutaneous edema
Fong describes a case of calcific tendinitis of the supraspinatus tendon in a 7-year-old boy and Sakamoto and colleagues describe calcific tendinitis at the biceps brachii insertion in a 3-year-old boy; although these locations are much less common in children [5, 16]. Fortunately, the aforementioned imaging findings are similar, regardless of the age of the patient or location of the calcium deposit. Although the clinical presentation of acute calcific tendinitis can overlap with trauma, infection, or a soft tissue mass as in this case, a thorough history and physical exam in combination with imaging studies can clinch the diagnosis in atypical presentations. Most importantly, recognizing this entity in children will prevent the misdiagnosis of more ominous conditions. Conflict of interest The authors declare that they have no conflicts of interest to report.
References 1. Bonavita JA, Dalinka MK, Schumacher HR. Hydroxyapatite deposition disease. Radiology. 1980;134:621–5. 2. Carrol RE, Seitz WH, Putnam MD. Acute calcium deposit in the hand of an 11-year-old girl. J Ped Ortho. 1985;5:468–70. 3. Chow HY, Recht MP, Schils J, Calabrese LH. Acute calcific tendinitis of the hip: case report with magnetic resonance imaging findings. Arthritis Rheum. 1997;40(5):974–7. 4. Farpour F, Maasumi K, Tehranzadeh J. Imaging of crystal deposition diseases. Applied Radiology Online. 2012;41(8):18–25. 5. Fong CM. Calcific tendinitis of the supraspinatus tendon in a 7year-old boy: diagnostic challenges. Hong Kong Med J. 2011;17: 414–6. 6. Hakozaki M, Iwabuchi M, Konno S, Kikuchi S. Acute calcific tendinitis of the thumb in a child: a case report. Clin Rheumatol. 2007;26:841–4. 7. Hansen U, Battista V. Pediatric trigger finger from calcific tendonitis. J Hand Surg. 2007;32A:1558–9. 8. Hayes CW, Conway WF. Calcium hydroxyapatite deposition disease. Radiographics. 1990;10:1031–48. 9. Holt PD, Keats T. Calcific tendinitis: a review of the usual and unusual. Skeletal Radiol. 1993;22:1–9. 10. Hulse N, Kumar A. Calcific tendinitis: an infrequent and misdiagnosed cause of acute wrist pain—a case report. Indian J Ortho. 2006;40(1):57. 11. Hurt G, Baker CL. Calcific tendinitis of the shoulder. Orthop Clin N Am. 2003;34:567–75. 12. Kraemer EJ, El-Khoury GY. Atypical calcific tendinitis with cortical erosions. Skeletal Radiol. 2000;29:690–6. 13. Millon SJ, Bush DC, Harrington TM. Acute calcific tendinitis in a child: a case report. J Hand Surg [Am]. 1993;18:592–3. 14. Ryan LM, Rosenthal AK. Metabolism of extracellular pyrophosphate. Curr Opin Rheumatol. 2003;15:311–4.
Skeletal Radiol 15. Sakai T, Shimaoka Y, Sugimoto M, Koizumi T. Acute calcific tendinitis of the gluteus medius: a case report with serial magnetic resonance imaging findings. J Orothopaedic Science. 2004;9:404–7. 16. Sakamato K, Kozuki K. Calcific tendinitis at the biceps brachii insertion of a child: a case report. J Shoulder Elbow Surg. 2002;11: 88–91.
17. Speed CA, Hazleman BL. Calcific tendinitis of the shoulder. NEJM. 1999;340(20):1582–4. 18. Torbati S, Daniel B, Geiderman JM. Acute calcific tendinitis of the wrist. J Emerg Med. 2013;44(2):352–4. 19. Uhthoff HK. Calcifying tendinitis, an active cell-mediated calcification. Virchows Archiv A 3. 1975;366(1):51–8.
