Images in Clinical Rheumatology
Gull-wing sign: A characteristic sign of erosive hand osteoarthritis
Signo de ala de gaviota: un signo característico de la osteoartritis erosiva de la mano
Sadettin Uslu
Department of Rheumatology, Ömer Halisdemir University Bor Physical Medicine and Rehabilitation, Training and Research Hospital, Niğde, Turkey
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C: Biopsy of Involved Skin depicting changes consistent with Vasculitis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sarmad Zahoor, Samara Siddique, Hafiz Mudabbar Mahboob" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Sarmad" "apellidos" => "Zahoor" ] 1 => array:2 [ "nombre" => "Samara" "apellidos" => "Siddique" ] 2 => array:2 [ "nombre" => "Hafiz Mudabbar" "apellidos" => "Mahboob" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574322000168?idApp=UINPBA00004M" "url" => "/21735743/0000001800000002/v2_202202161206/S2173574322000168/v2_202202161206/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Images in Clinical Rheumatology</span>" "titulo" => "Gull-wing sign: A characteristic sign of erosive hand osteoarthritis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "127" "paginaFinal" => "128" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Sadettin Uslu" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Sadettin" "apellidos" => "Uslu" "email" => array:1 [ 0 => "sadouslu@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Rheumatology, Ömer Halisdemir University Bor Physical Medicine and Rehabilitation, Training and Research Hospital, Niğde, Turkey" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Signo de ala de gaviota: un signo característico de la osteoartritis erosiva de la mano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 636 "Ancho" => 1305 "Tamanyo" => 73170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hand radiograph showing gull-wing deformities in DIP joints.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 54-year-old woman presented with a 3-year history of pain and deformity of distal interphalangeal (DIP) joints in both hands. The pain was inflammatory in nature, with early morning stiffness of >1<span class="elsevierStyleHsp" style=""></span>h. The patient's personal and family past medical history was unremarkable. She had partial response to various nonsteroidal anti-inflammatory drugs (NSAIDs). Physical examination revealed tenderness, swelling and decreased range of motion in the DIP joints. Laboratory evaluation revealed high ESR (39; range, 0–20<span class="elsevierStyleHsp" style=""></span>mm/h) and CRP (18; range, 0–5<span class="elsevierStyleHsp" style=""></span>mg/L) levels, with negative RF, anti-CCP and ANA. Based on clinical and laboratory findings referred to an inflammatory type pain due to the presence of joint inflammation. X-ray of the hands documented typical features of erosive hand osteoarthritis (OA) in DIP joints such as joint space narrowing, subchondral sclerosis, marginal osteophytes and erosions in the central portion of the joint giving “gull-wing sign” (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient had a high level of pain (VAS<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>75<span class="elsevierStyleHsp" style=""></span>mm). Treatment with prednisolone (10<span class="elsevierStyleHsp" style=""></span>mg/day) and methotrexate (10<span class="elsevierStyleHsp" style=""></span>mg/week) was initiated (patient consent form was obtained for treatment). Significant clinical improvement was observed on her pain (VAS<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>mm) and morning stiffness (less than 5<span class="elsevierStyleHsp" style=""></span>min) within four weeks of the treatment. Additionally, ESR and CRP decreased to normal levels.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Hand OA is a subtype of OA that consists of several phenotypes, including interphalangeal (IP) OA, thumb base OA and erosive OA. The term “erosive OA” specifically relates to hand OA with erosions in the IP joints. Erosions on radiographs can be defined by different scoring methods.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Erosive hand OA is often called “inflammatory and degenerative hand OA” condition of the IP joints, but the underlying mechanisms are currently unclear.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Clinical features attributed to erosive OA include an abrupt onset of severe hand pain with variable degrees of stiffness, erythema, swelling and limited function of the joints. No formal classification criteria exist to define erosive OA. Erosive OA is a radiographically defined phenotype characterised by erosions and central cortical collapse.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The “gull-wing sign” describes the distal convex paracentral erosions with subchondral sclerosis and marginal osteophytes on radiograph. In a small cohort study, performed in erosive hand OA patients, it was reported that about 12.6% of the examined DIP joints had gull-wing deformity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> The primary goal of managing hand OA is to control symptoms, such as pain and stiffness, and to optimise hand function. Optimal management of hand OA usually requires a multidisciplinary approach. The objectives of management are: (1) non-pharmacological modalities (education and training in ergonomic principles, exercise and orthoses); (2) pharmacological options (paracetamol, topical/oral NSAİDs, chondroitin sulfate); (3) surgery (trapeziectomy, arthrodesis or arthroplasty). Intra-articular injections of glucocorticoids should not generally be used in patients with hand OA, but may be considered in patients with painful IP joints.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Also, the Hand Osteoarthritis Prednisolone Efficacy study showed the efficacy and safety of short-term prednisolone in patients with painful hand OA and synovial inflammation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Peer-review</span><p id="par0015" class="elsevierStylePara elsevierViewall">Externally peer-reviewed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declared that this study has received no funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">Informed consent was obtained from all individual participants included in the study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Peer-review" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Informed consent" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-01-22" "fechaAceptado" => "2021-04-25" "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 636 "Ancho" => 1305 "Tamanyo" => 73170 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hand radiograph showing gull-wing deformities in DIP joints.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atlas of individual radiographic features in osteoarthritis, revised" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.D. Altman" 1 => "G.E. Gold" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.joca.2006.11.009" "Revista" => array:6 [ "tituloSerie" => "Osteoarthrit Cartil" "fecha" => "2007" "volumen" => "15" "numero" => "Suppl. A" "paginaInicial" => "A1" "paginaFinal" => "A56" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Synovitis and radiographic progression in non-erosive and erosive hand osteoarthritis: is erosive hand osteoarthritis a separate inflammatory phenotype?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I.K. Haugen" 1 => "A. Mathiessen" 2 => "B. Slatkowsky-Christensen" 3 => "K. Magnusson" 4 => "P. Bøyesen" 5 => "S. Sesseng" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Osteoarthrit Cartil" "fecha" => "2016" "volumen" => "24" "numero" => "April" "paginaInicial" => "647" "paginaFinal" => "654" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "OARSI Clinical Trials Recommendations: design and conduct of clinical trials for hand osteoarthritis" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "OARSI Hand Clinical Trial Recommendations Work Group" "etal" => true "autores" => array:6 [ 0 => "M. Kloppenburg" 1 => "E. Maheu" 2 => "V.B. Kraus" 3 => "F. Cicuttini" 4 => "M. Doherty" 5 => "R.L. Dreiser" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Osteoarthrit Cartil" "fecha" => "2015" "volumen" => "23" "numero" => "May" "paginaInicial" => "772" "paginaFinal" => "786" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and radiographic distribution of structural damage in erosive and nonerosive hand osteoarthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Addimanda" 1 => "L. Mancarella" 2 => "P. Dolzani" 3 => "L. Punzi" 4 => "A. Fioravanti" 5 => "E. Pignotti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arthritis Care Res (Hoboken)" "fecha" => "2012" "volumen" => "64" "numero" => "July" "paginaInicial" => "1046" "paginaFinal" => "1053" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2018 update of the EULAR recommendations for the management of hand osteoarthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Kloppenburg" 1 => "F.P. Kroon" 2 => "F.J. Blanco" 3 => "M. Doherty" 4 => "K.S. Dziedzic" 5 => "E. Greibrokk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/annrheumdis-2018-213826" "Revista" => array:7 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "2019" "volumen" => "78" "numero" => "January" "paginaInicial" => "16" "paginaFinal" => "24" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30154087" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Results of a 6-week treatment with 10<span class="elsevierStyleHsp" style=""></span>mg prednisolone in patients with hand osteoarthritis (HOPE): a double-blind, randomised, placebo-controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.P.B. Kroon" 1 => "M.C. Kortekaas" 2 => "A. Boonen" 3 => "S. Böhringer" 4 => "M. Reijnierse" 5 => "F.R. Rosendaal" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2019" "volumen" => "394" "numero" => "November" "paginaInicial" => "1993" "paginaFinal" => "2001" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001800000002/v2_202202161206/S217357432200017X/v2_202202161206/en/main.assets" "Apartado" => array:4 [ "identificador" => "5795" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in Clinical Rheumatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001800000002/v2_202202161206/S217357432200017X/v2_202202161206/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357432200017X?idApp=UINPBA00004M" ]
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