Document NeQYbm2DrXNY7BO8402QLDybb

-^sFkV-' --V>r; * *' rr'-J/^*_V" -r"'' '.:7 ?'' --'-Y '.. * . -* /*?s>SK. ^ * Report of 31 Case* * > Rex H Wilson, Ml). IVrflittm E. McCormiek, MS, Cninil l. Tmum. Ml), and Jnhn L. Cretrh, MU'"" A&7 ...v >-. * .-.' '*T v?-5?]"<tTri J1 eaees'Of acroosteolysi* of the hands of workmen associated with vinyl chloride (CH.-CHCl) polymerization ' " ?-*f* ^ntHUt, the osteolysis was specific to the distal pha langes of hands and was frequently associated with RayVyi, naud> symptoms. Affected personnel ranged in age from % 2$ tf 47- The disorder is believed to have resulted from [!jrV. t,cseibJftatioa of physical intuit, chemical insult, and -~>*rpera!eflaJ idiosyncrasy. The specific causes are unknown. <*'*;The .prevalence was found to bo less than 3% among 'V. s'npioyoos porforming similar work. No cases were found * In workmen using or processing the polymer or menu^'tectwing commercial resins. t<aring mid-1964, several complaints came tn our D attention of soreness and tenderness of the >.,Afliigrtip-ofrworkmen in a manufacturing plant .Tpoiymeriaing'vinyl chloride (CH-CHCl). Compre- hensive examination* of those individuals revealed Nothing of significance except a '`Raynaud-like phe- -^'-TsSmanon'-' ol'^ho hands, and in some cases, definite j^/tthangei ofthe-ldistai phalanges-were apparent on . * ^metttgenogrvms of the hands- Since then we have -V?? observed additional cases of this unusual syndrome, ft is the purpose.of this manuscript to summarize ardour observations. - - -- .v,* ^ Description ol Syndrome `^V^ tvTo date we have observed 31 cases of hand die^riord$t* among 3,000 personnel involved in vinyl .HgV ehlofridft mlUafllniUuifBahcbtUurfUinfgtl,. Ba4nIUd ^pWolIy/lmllCeUriMzabtlUioUn. nAull 'ti/have been men; between the ages of 26 and 47. We have ridfropservedasy ethnic or racial .tendency for dft syndrot^k. The greet majority-have been char'v^^cierTred'by. two coramon factors: symptoms likened those -esaribad hr Raynaud's phenomenon and icanafdfilprif .of the.distal.phalanges. A few have symptoms but have (ha roentgenographic ,,Jar\ eridpnce'ofaczposteolyeis. Several of the patients ^p^kaveeJiteRistslria'laatoh(r oo. the dorsal surfaces of ` ^7j^'^^di'ao'd/1oreamia^ with~e rope-like appearj|9* `.cs^Nuem|bliac,changes sometimes seen in sdaro- m- SMteLXHVimen. F: Ooodndi Co . Akron. Ohio. \ '8*frtpl1IRwii* iMPtl Miia 8t Alow, Quow443mISi<kDr.. wWui-i- ^ --'1 f- derma. Some have clubbing of the ringers. Only a few ' of the cases have sought medical attention because/* -W of symptomatic complaints; the majority have beeir-* .. . * found through x-ray examinations of the hands. A summary of the physical findings of the ob-'. ?. served cases is shown in Table 1, and a detailed de- - *_'r.' scription of the two predominantly common syrap-V . toms follows; \ - ***'\. Raynaud's Phenomenon.--This symptom ,com plex has occurred in varying degrees, with one or both hands involved. Generally, its ctfert is observed as marked discomfort on exposure to cnid. None of the cases have exhibited vascular changes of the feet. A unilateral sympathectomy performed on one of the most seriously affected cases relieved most of the symptoms on that side. The acroosteoiysis was not altered by the sympathectomy. Roentgenological Changes.--The most unique characteristic of this syndrome is the unusual roent genological findings. These are described as acroos- - - " teolyxis and are illustrated in Fig 1'. It may be present - ~ ' in all of the fingere and readily observable, or only in -^ one ringer and barely discernible, as illustrated in - Fig 2. X-ray films of the feet, as well as those or the long bones and of the skull have been made in some;'//,, ot these cases, with no osteolysis found other than *w ~ in the distal phalanges of the hands. Acroosteoiysu is a rare clinical entity, with only-'' 72 cases of the familialtype reported up to 196o. ac*. - cording to Cheney in his. excellent review.' TH ~ * , diagnosis of acroosteoiysis requires expert- roent- : genologicai technique and. knowledge. It. has. been. /. our observations that early case*-of acrooateolysu* - will he missed by the. roentgenologist not famsiar \ with this condition. All of the cases on which we are*' r* reporting have been confirmed by at least jtwtf ex- ; c'* v * perienced roentgenologists working independently. / We established the. following reeatgenographic*^ ' .* criteria for our dlagnosee. These are- the resptt'ofcc; -~Wi: uur having viewed aevarei thouMcd-x-ray fUrna oV ' the hand in our search for th*'cause dl Che^&Ot-^ .*- drome. ' ^ *- ^ 1.. Gen, eral: _R_ne, nt-genorpaphically. acrjqciate- ol^si^ ^ as found ur- worker*.*! are exposed' w " W f:r> - -- - - \;%n . . -1- -'f*1 1 'It.s' RSV 0008865 _ _ gtraiewJiaV'diflerfnf from that found in ^taQporonrwith aoosfteolysi* and in fa-' r' 'T1 'r-* ggckrpsi* wfthicrooatsoiysia. In oateopo* fwithaeroosteoTyeis that* may be compression ^___ ^"ths-spme* aruf basilar impression of Mkitull^ aloof with destruction of the nudpha- of these findings have been seen in jfl^e workera* The changes in the distal phalanges judeiniilerm both conditions. NWUl'l HMMM enwiKiw iiwew *wiw0*b tfmmrnm. **T90MW*4t tf aimatema. <1a--svaMtluilely-awu<manst*mm, Me* mmi gening; Of the shafts of the long bones and clubbing - the metaphyseal ends. The phalanges of the hands ,,y^va>ancrmetacerp4]s were'foreshortened, and the distal phalaxlges showed acrooateolytic changes. The feet ,554.'showed the same changes, except that the distal i#Kr phalanges were not fragmented. TheTehas been no evident destruction in the mid or proximal phalanges of the thumbs or fingers of '(*1*1 these individuals and no evidence of a lytic, deatruc- *V>J ' tiye lesion in the feet. -*We have not observed any loss of calcium salt in Tjf* 7>*`*v the bones of the wrist and remaining bones of the * ' ban^l and phalanges in any of these individuals, and there haa been no evident sclerosis of the wrist land hand boose 2.'Mild stage: The earliest change found in , afcrooatselyaiem these worken has been a Iosa of the .. cortex of one or sure of the tufts of the distal phar ln'TiUf!i.f" i th no destruction of the tuft or shaft of diatal phalanx. The;, next- more advanced stage may be a small, .half-OMR cut in the cortex of the tuft of one or more 2. MiW stage of acreoataolySi with half maon oe> fact af Wstal phaiaiia of MS flngar.. 1. towimlyii with invoivafnant of Oistai pftalangaa of oil flngan. Jp."'*-: v'*T~* , > "r ,"VV 'M25 m V-5-V. *b-\ ? - if >' - ^ **' RSV 0008866 Z X*' *." : jlfrwohn. gatj^tfre carta* of-thadiatal phalanx of Z .-; iami^ahnr^n.: V *'!: -.? -' i^TA^vancod stags-A aim severs lytic destruc* crf?/~ ^sokmvt bm acomplet* loot of tha tuft and a por- ^^JwiLdi'tH^ahafi of on* or more distal phalanges \ -V ' J^WtHUitntod-in FIg.1 in which tha tuft of the diatal ' ^*^&alaax o2'tha right thumb and tha tuft of tha v> -.- dlstiiTphalanx of tha lift fifth- finger art completaly . " ' J^y^jhian^ nVi *-hTirmirhanri !yw- ^ a portion of tha diatal rim of tha tuft remaining, ^om ^ pnxiaal portion of tha tuft and a .portion of-tha abaft of tha phalanx, which can also ba t V^vridantified In tha remaining phalanges in Fig 1. ' ' v^Thia lose may ba of a tnnsvene nature through tha 4. Healing stager tn'thia phase,* them, is often.definite fragmentation- of tha remaining tuft* and of- tha filled-in area where tha previous destruction* waa not^d through tha abaft of tha diatal phalanx: This may gw on to a complete bony union or remain1'C as a fibrous union with fragmentation. In Fig 3 and' ! 4, x-ray films of tha same individual well demon- - _ strata tKla. This employee had almost complete reunion of the multiple fragments when first teen in November 1965 and again in November 1966 (Fit 3). In the latter, the completely healed-shaft* end tufts of the diatal phalanges are indicated by nor residual fragmentation with fibrous union. There is a definite shortening of the shaft and a widening of * . RSV 0006867 Z* ACAOOanOLYStf-MlSOM ET At, ... , r ^aSafpand tutCbow in the transverse-and tbs facBpeetecmt diametee-This is moat likely duo ta TsMe 2.-Age WstiibeOsH w Csms ?TnK;riftyn ofconstant pnoun, and by the nor- pel.tension of.the soft tissues, particularly tha tan* ' 4{bb^J:tbad)ti^pha^|a. son 30-39 ] 4049 ' ' 44 4 ' U ** ". tfeaupatioiial Aspects of Syndrom* ,, J .Z. *< : -,,* * ^Basedfupon bur observations of these 31 cases, it K>appean aelf this syndrome may be of occupational ;~^&rigm.aBd la somehow related to the process of vi- A^:ynsyl`%hlonde polymerization. Its specific cause if not f presently known. We are performing extensive re- starch man effort to find the cause. Two other pa* '^w^'pena referring to thecondition have appealed in the ^IvEgrature. The publication by Suciu et al' contains boapedfic information, and merely alludes to some ,. htyf problem. That of Cordier et *1* preaenta case 3Vjj`*y,.hiatoneswith symptom* similar to many of the cases yrrteenihs This syndrome differs from idiopathic *aad acrooeteoiysia is that only the hands - VJnri,Chloride Polymerization Procesa ^FqiyvinyI-ehToride is a widely used synthetic resin. * jTS'Xfc has bean manufactured commercially for more 30 yean and is used in upholstery fabric, floor '^fcwttd walT tQe, 'Wins inanlation, phonograph records, j. . Mnndjnany-other'commonly used commodities. For j^Ata^manVof these usee* the resin (CH3CHG) is mixed ffiriti^thaV'materials. to.achieve the desired physical ibhararf.eriaticK.The hand syndrome occurs apparent* posed to vinyl chloride or to ^p^jr^dther'dumicals oaed in the manufacturing procesa * itself st both In. addition to out axami- nations of 3,000 personnel performing vinyl chloride manufacturing and. polymerization, we have exam ined more than 1,000 individuals who handle the finished resin or who process it into plastic prod- * ducts. So cases of acrootUoiytit have been found in. - these 1,000 persons* r v. Basically, the manufacture of polyvinyl chloride consists of polymerizing vinyl chloride. The reac tion is accomplished in closed containers (polymer- izers) with suitable catalysts and emulsifiers. Copolymers, formed by combining vinyl chloride with other monomers, create variations of the homopolymer. These are commercially produced. Following polymerization, the resin is washed, dried, and sold as a finely divided white powder. The polymerization operations are carried out ia~ closed processes and provide little opportunity for employee exposure. Following the completion of the polymerization reaction, periodic cleaning of the wails and agitator of the polymerizar is necessary. The frequency of this cleaning and its method varies with the type of material used in these vessels and with different manufacturers. The most common practice has been to accomplish the cleaning man ually by using hand scraping technique*, with work ers spending several hours each day on this job assignment. Personnel performing this job am com- - manly referred to.as "polydstnea.1* " - '5 *** " W%t^^'tora HsaiaCai amteolyets ttfi only minor rosoffsa smwain* jejeqr* ipMi Mgfrfc tarns laSM*Mai n*.mom* aftarrC 'iS*a v . ' Ve >* <\r: > -<-r -r&rxt r3 y*->5avi-rw * ftSV 0008866 -w- a > r i^v^yr^v-. ,,, ACA009Tt0LYSiS-WlU0N ET t,- --< . *-_. -'-. - -v.. 5*1 -V'J;.>- $&* ' '\^..Wi.'e.jh*a**ve>' a..t.temj"p; te_d. t."o study the relationship of - ft&histqyatt&tha eccnrraacs of the Hi--i--. Twen~v* 3x*MTt.^ our 31 have either b--n on the ^"polyd--nag* jbb_--eignmaot at the time the *yn/`drccna Ippeared' or h--ra hod that assignment at ^ soma-time in tha past. This job assignment is the -- /^ oniy one showing any poaitiva corral*cion with tha ' -oCcmranceof the syndrome. '.^Attack Ret*.-The syndrome ha* a low attack ' . rata. Oul experience indicates it occur* only in less * thap.J2%..of all production employees who at one rc*Jfcnn*have had polycleaning experience. : Distribution.-The youngest of our cases is ara"" to some degroo through the prolonged: hand crapingoperations as wall as the occasional use of ->r` hammers to remove the residues. In support of the * physical insult factor, we have quite recently ob served theieffects of a injury to an existing, case of thia syndrom. Figure 4 (Itft) showe an..', ,fc-^ x-ray film of the left hand of the ftiet of the-- casta A* of scroosteolyais (accompanied by Raynaud's symp- toms and akin nodules on the dorse! surface* of the- - hands). The bone damage is quite limited. Figure 4 (right) show* the --me hand with tha roentgeno- - gram taken four months after a crushing injury to the mid finger, with lysis having resulted to Che tuft of the distal phalanx. We believe thia activicy waa . stimulated by the trauma. *f ',^2Syeen old; and the oldest ia 47, with the majority !' 1 the 30 t39 age group. The complete dia- v/ tribution ia shown in-Table 2. . * J % JTie appearance of. the syndrome among younger 7Vv--v-'employa-- may-be infi"*"*--* by the fact that the t*..^-.. .potycLaaning job ia one of the initial job assign* t* ,\ft menu into-which smploya-- in such plants are ^ly^hirad: * -< ;.sv** >..~ 3^* *&rrncubatiam.Period.--11 this syndrome is related to occupational factors, -- we believe, then the time .rv^' -of'exposure to the-- factors should be significant. .^'-`JWe have investigated the time spent on polydean* r_Jr \p*Z uafr and, although accurate job*time assignment in- jhnnation la difficult to develop, it appear* as if none i the-- .{teas has had la-- than 12 months poly* L.,%..'jl'lBaioWnn . ,,.... . . .. _ Personal idiosyncrasy appears to be an important factor because of the low incidence of occurrence of the disorder. This is especially significant because, although all polydeaners are subjected to ea--no*i- ~ ly similar chemical and physical insults, the ind* dence of this syndrome ia vary low, and the explana* * tion for this can only be made on the basis of person- ^ al idiosyncrasy. We suspect pertinent factors here ~ . are related to the individual*! vascular system, the nerves controlling the blood supply to tht fingers, and to the specific type of collagen in the individ ual's hands. We are in the process of investigating the-- factors. We have observed no --nous disability in any of the-- cases. A few have been partially disabled be* causa of hand sorene--, to the extent that score _ restriction in manual activity was necessary. Im provement in the symptoms, -- well -- in the roent rsQSKstr oar knowledge, thin ia a unique and, with the [^^M**oxoeptioa; of'refOreDceft 3 end 4, previously unro* jy^gj^iygtod^disordenThe- specific cause is pre--ntly genological findings, has occurred ia many cases without adequate explanation.' ..* V ^*4 Wc wish to emphasize that' no cases have, b--aJ(; found, after extaninv* --arch, in individuals cither - *** ^ unknown, although it appears to be related to the i-Jv^ coanufactur* of-vinyl chloride and polyvinyl chlo^g^j^Jadeir Wot only are the- x-tay findings of themselves working with tha finished polyvinyl chloride or' its.vj' copolymers, or in proce--ing the polymer into plastic . ... products. In the-- processes, more exposure to -the-`*4*;'" ' j^TpinidusCbutwhan accompanied by the symptoms of polymer occur* than do-- is tha manufacturing *^*<*ilsynaudYphencihienon, the syndrome becom-- ex- the polymers themselves. --* ^ " S5?^S^1JrD"iy* specific*Ag far as we areaware, this has not We pr--sntly believe that personnel assigned: to;. .^^^een an. observed .wpnnso..to, any- toxicant in any polycl--ning should be^ evaluated, prior. to aigigaJy.V-4.-j .*TM2hsl?jpodes:Wehave attemptad to arrive- - (sent, for any evidence of collageri disea--,'osta^lv'r ym$, ** an explanation of Ita^cause, -- well -- the phyaio- olysia of the hands,.or abnormal resport---oi thei ^ 2- V: , logicsT mechazriao whereby the extram* specificity hands to cold inaulL Any evidence of tbs axistencej^^v" 4 Ts'.lA^fbr- the^hel'fibeleng-- of -the hands occurs, but of sny of three fartore should contraindicate the a* T yrg* *i b ssriViwnrr--tfiTll. Wtrbsiieyw the condition ia- sixnmcnt of an inigvidual. to ^*noiycj--ning,^: and -4'^v:7 '^"snH^q^tfgs*^jhctorJall; of which must ^ t;ftypeouiraaese alchemical, insult^ i ^*g^avphy*ldik faeuiKfldd fjjY&jymmat iffiosyacxaey. I IWIHIM IIIMUl, Xo*c.--cur UfrMooMvToWMMoWr more at \ ^4g?^haJmwmervc^alyst*i and intermediata reaction A^low degri -{ Uj^^^exposuratn.the--.cm, from contact with the* m............................... inpthe polymerize* on nalf:ddantiiiih.ofc,v*por^ abeorbed eitber-per*' . -i:A--K.kVeb OiWeiiwidi aiiiiwiWsirerei Sr*>4e U Oe--a--> Wnmilyiii --4 Op--e-rf. c--?%a-- mm imrtowi ism v .'.g'-rjj 9i Smqu. U ___ rt*mCVeEiflfai, I4r CiMi--dt SfcidW^v^^-. ,-- -- C3wwe^e-VWiL;V^iwn> *>-*$?'* JJi, t al^' Awu--Illy It l iHie Cit--we A*- _.-4'. Be-- Ouw--e. AJiW m-W--US tyAeinelev^ - - C-- MtdTruwf#*ni9**iseg.;* -,.r v- r- " ................." '--------- RSV 0008869