Calcium barbotage for acute calcific periarthritis of the finger

INTRODUCTION

Acute calcific periarthritis of the finger is an uncommon yet debilitating condition marked by the deposition of calcium crystals near the joints, resulting in intense pain and limited mobility.^[1] Calcium barbotage, a treatment method often discussed in relation to calcific tendonitis of the shoulder, has been widely documented. This technique has demonstrated excellent outcomes. The following case report details a specific instance of calcific periarthritis of the finger, highlighting the immediate post-procedural pain relief achieved through calcium barbotage.

CASE REPORT

A 35-year-old right-hand-dominant male presented with an 8-day history of worsening pain, swelling, and redness in his left hand, specifically around the fourth metacarpophalangeal joint. He reported no associated fever or chills and could not recall any trauma or insect bites. Notably, there was no pain in any other joints. Routine blood tests, including a complete blood count and erythrocyte sedimentation rate, an magnetic resonance imaging (MRI) was performed.

The MRI revealed nodular T2 hypointensity primarily along the radial aspect of the fourth metacarpophalangeal joint, with partial encasement of the head of the fourth metacarpal. Extensive surrounding edema was present, but the bones appeared normal with preserved marrow signal and intact joint space cartilage [Figure 1]. A subsequent computed tomography (CT) scan was done to characterize the T2 hypointensity better and differentiate pigmented villonodular synovitis from calcific periarthritis. The CT confirmed amorphous calcific deposits along the radial aspect of the metacarpophalangeal joint [Figures 2 and 3]. The differential diagnoses considered were acute calcific periarthritis and gout; however, serum uric acid levels were found to be normal. Based on the CT and MRI findings along with the blood parameters, the patient was diagnosed with acute calcific periarthritis.

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Figure 1:

(a) Coronal T2 and (b) proton density fat-saturated images showing an ovoid T2 hypointensity (red arrows in a and b) along the radial aspect of the fourth metacarpophalangeal joint. Extensive surrounding edema is seen.

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Figure 2:

(a) Axial and (b) reconstructed coronal computed tomography images showing an ovoid calcification (red arrow) along the radial aspect of the fourth metacarpophalangeal joint corresponding to the site of the T2 hypointensity on the magnetic resonance imaging.

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Figure 3:

Reconstructed 3D coronal computed tomography image showing an ovoid calcification (red arrow) along the radial aspect of the fourth metacarpophalangeal joint.

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To treat the condition, ultrasound-guided calcium barbotage was offered [Figures 4 and 5] to which the patient consented.

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Figure 4:

(a) Transverse and (b) longitudinal ultrasonography images showing the calcium deposit as an ovoid echogenic area (white arrows).

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Figure 5:

Ultrasonography-guided calcium barbotage - Needle (Block arrow) targeted to the calcium deposit.

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Before the procedure, routine blood investigations such as complete blood count, ESR, and prothrombin time international normalised ratio were cross checked to rule out the possibility of any infective process/unknown bleeding disorder. An informed consent was taken from the patient.

The procedure was then conducted under strict aseptic conditions, with local anesthesia (2% lignocaine) administered subcutaneously. An 18-gauge needle was then advanced into the calcific deposit under ultrasound guidance. A 10 mL Luer-lock syringe containing 7 mL of normal saline was connected to the needle hub, and saline was pulsed into the calcium deposit. The dissolution of the calcium was clearly visualized on ultrasound, and some calcium was aspirated into the syringe due to the pulsing action. This process was repeated 4–5 times. Afterward, the needle was repositioned outside the calcific deposit, and 20 mg of hydrocortisone along with 2 mL of 2% lignocaine were injected into the periarticular region before completely withdrawing the needle. Please note that the endpoint is not complete calcium aspiration, which is seldom achieved. The idea is to break the calcium deposits and instill an anti-inflammatory agent in the surrounding which will facilitate the calcium absorption eventually.

Immediately following the procedure, the patient experienced a rapid decrease in pain, with the Visual Analog Scale (VAS) score at rest dropping from 10 to 6. In addition, the range of motion in the finger improved significantly. No immediate complications were observed. After 24 h, the VAS score at rest further decreased to 1, and during activity, it fell to 3, though there was slight discoloration at the injection site.

DISCUSSION

Acute calcific periarthritis is characterized by juxta-articular calcium deposits associated with severe periarticular inflammation and pain.^[1] These deposits may consist of calcium hydroxyapatite or other basic calcium phosphate crystals. Often, the underlying cause is unknown, and patients typically present with involvement of a single joint. Similar deposits in tendons are referred to as calcific tendonitis.^[1,2] The tendons around the shoulder are the most commonly affected sites, followed by the hip and knee.^[2] Involvement of the hand and wrist is less common, accounting for approximately 2.4% of cases.^[3] When these areas are affected, the flexor carpi ulnaris near the pisiform bone is the most frequently involved site.^[4]

Patients often present with a rapid onset of pain, swelling, redness, tenderness, and restricted range of motion. Plain radiographs typically show dense amorphous calcification in proximity to an articulation or tendon. While the disease is usually self-limiting, the pain during the acute stage can be excruciating, often rated 8–10/10 on VAS, and can be debilitating, necessitating pain relief.^[2,4,5]

There are no standard management guidelines for treating or initially managing pain in this condition. Treatment is typically conservative, involving non-steroidal anti-inflammatory drugs (NSAIDs).^[3] However, the efficacy of NSAIDs varies, and pain and discomfort may persist for a prolonged period. NSAIDs may take at least 2 weeks to alleviate severe pain, with some patients experiencing residual pain for up to a year.^[6] In a study by Kim et al., none of the 10 patients reported being pain-free at 6 months.^[7]

Ultrasound-guided calcium barbotage with steroid injection is a well-established technique for treating a similar condition in the shoulder (calcific tendonitis of the shoulder). The mechanism of action involves fragmenting the calcification with a needle, increasing the surface area for faster resorption.^[8] Calcium barbotage is less frequently utilized for calcific periarthritis in the finger and hand. This may be due to the overall low prevalence of hand involvement, a lack of confidence or reluctance to approach small joints under ultrasound guidance, and limited literature evidence.

Nevertheless, the technique is effective and gratifying and often provides significant pain relief and improvement in mobility. Rarely, there may be a pain flare-up due to calcium spill post-procedure but eventually, there is significant improvement. When performed under ultrasound guidance, it is relatively easy to avoid nerves and vessels, resulting in minimal complications, which are typically limited to skin discoloration and, rarely, nerve injury. A few tips when performing this procedure in small joints like the finger are enumerated below:

• Use high-frequency small footprint hockey stick ultrasound probe

• Use a 20–22 gauge needle available with syringes. Avoid the spinal needle

• Use 5 mL Luer-lock syringe and perform gentle lavage using small volumes (1–3 mL saline)

• Avoid tendon injury

• Post-procedural steroid injection

• Apply compression dressing and brief splinting to ease post-procedural discomfort.

CONCLUSION

Calcium barbotage under ultrasound guidance is a safe and effective technique for treating patients with acute calcific periarthritis of the finger and is associated with very few complications when performed correctly.