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Unusual and memorable

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A 39 year old man was referred with increasing swelling of the right hallux, and a similar, smaller swelling on the left side. This was progressive over the preceding 12 months, and was painful on weight bearing. There was marked, diffuse soft tissue swelling, tenderness, slight restriction in joint range and associated nail changes (fig 1). Plain radiograph (fig 2) suggested bone proliferation, and computed tomography was requested (fig 3). These show florid bony excresences arising from the terminal phalanges of both halluces, thickened cortices, normal medullary cavities, and extensive soft tissue swelling.

Figure 1
Figure 2

 Periostitis and bone proliferation may be associated with soft tissue swelling and nail changes on the same digit, and can be an early feature of psoriatic arthritis (and other spondyloarthropathies) before significant joint involvement occurs. Periosteal bone may entirely cloak the cortical surface (particularly of the terminal phalanges of the toes), and when associated with trabecular thickening can cause the entire phalanx to appear radiodense, the so called “ivory phalanx”.1

Contributors: d o’gradaigh, c blundell, t marshall, k gaffney, p chapman. Norfolk and Norwich Hospital, Norwich.

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