Document x1DqEENpK74Jmw2JwQKkQ30e6

V" ., : w-w. -.- , :, VOL 201, NO , AUGUST 2T, 1*67_ rji vT-"^*'->tlri. 31 UMt'Dl acroosttolysi of the hands of workmen 'aasoeiatetf with vinyl chloride (CH.CHCJ) polymerization ?*i -~4*^ J*>racesses, the osteolysis was specific to the distal pha* langes of hands and was frequently associated with Ray- 'X' 'cm. naud'r symptoms. Affected personnel ranged in age from ' N's ^ 47. The.disorder is believed to have resulted from a. combination of physical insult, chemical insult, and !* ^^.T^peribrial idiosyncrasy. The specific causes are unknown. ^:^.>FevaU. was found to be less than 3% among < , ^ti^.employees performing similar work. No cases were found .1 .In woakmen using or processing the polymer or many i factoring commercial resins.V * .Ms ' J * , * * :* - *- ,1 o*.* ; V: . i^''*r;-^.TVor5ag mid-1964, several complaints came to our ,, I / attention of soreness and tenderness of the .^.fijlgertipa* of'workmen in a manufacturing plant 7 polymeriiing'vinyl chloride (CH-CHCl). Compre- \nr hensive examinations of these individuals revealed i^v-iothing of significance except a "Raynaud-like phe- v^y;-umeaqpV of-the hand* and in some cases, definite ^T/fthanges oi"the\distal phalanges-were apparent on V-'.V^pentgenograms of the hands. Since then we have .`'".^observed additional cases of this unusual syndrome. Tt is the purpose.of this manuscript to summarize **5<*~bkr observations. -- - -Vi,..- - * gfl/, , icZ,: Description of. Syndrome 7*To data we have observed 31 cases of hand disi ^^lorders among 3,000 personnel involved in vinvl A`ll IVe *'' ^ ^..`have ribfro'pserved any ethnic or racial .tendency for * - syndrome,. The great majority-have been char" two common factors: symptoms likened J - fc* ihosa' -ascribed tax Raynaud's phenomenon and ' aajdaiebJvsisof the.distal, phalanges. A few have v^^ha&'gio symptoms but. have .the roentgenogr&phic Zi ^;._eridanctf;oracxoosteolysia. Several of the patients * ^^^have.e^ternal^kizi'lesionp^on. the dorsal surfaces of with -a rope-like appear- . ................ ... *.. ' . derma. Some have clubbing of the fingers. Qnly-.a of the cases have sought medical attention because: of symptomatic complaints; the majority have beeD--* 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*J ^.. * 'l scription of the two predominantly common symp- v' toms follows; * -v' - Raynaud's Phenomenon.--Thin symptom ^com^. plex has occurred in varying degrees, with one or' . . both hands involved. Generally, its effect is observed as marked discomfort on exposure to cold. 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 acroosteolysis was *' not altered hy the sympathectomy. Roentgenological Changes.--The most unique . - ^ characteristic of this syndrpme is the unusual roent- ... genological findings. These are described as acroos^ - -'.V teolysisand are illustrated in Fig l. It may be present : in all of the fingers and readily observable, or only in r, . "J; ; one finger 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 somf'^v ";sC ^ ` of these cases, with no osteolysis found other than + ;7V in the distal phalanges of the hands* - , * - - Acroosteolysis is a rare clinical entity, vrith*ority',',.-' 72 cases of the familial, type reported up to 196o.'ac^. - "'> cording to Cheney in his excellent review.' Tne-'*-~ -1 diagnosis of acroosteolysis requires expert, roent-genological technique and. knowledge. It.has,beta.. our observations that early cases-of acroosteolysis -'- will be missed by tha roentgenologist not fam&iar ^ .- with this condition. All of the cases on which we arerf'-1 reporting have been confirmed by at' least^1wo; ex-.-^ -C4''- . * perienced roentgenologist* working independently. * ^ We established the, following roentgenographic^.C'-l': criteria for our diagnoseis.'These ar'the resyh` o^` our having viewed several thousand-x-ray filma. a/ ' ^ With'aCTbcstebiysis there may be compression* CilTtht-apme, .'and'buiLu impression of-- : j-'^L `/kullj:>rbnf with destruction of the midpha- ->* ` es^NOna pf these findings have been seen in. . _ jfreMi'woritara* The changes in the distal phalanges "v.;-. ^riaunilsc'm both conditions. '" 'V: ^arOsteosclerosis'SCToosteolysis observed by Andren ` **.eC^alL'(iJniversity-'HoepitaI, Malmo, Sweden) in /' frnnyshowed diffuse sclerosis, with cortical thick- ^/-^enlnc. Of the'shafts of the long bones and clubbing /L' ,o(the metaphyseal ends. The phalanges of the hands ..^^metacarpals were foreshortened, and the distal phalanges showed acroosteolytic changes. The feet -Showed the same changes, except 'that the distal **' phalanges were not fragmented. There has been no evident destruction in the mid ** proximal phalanges of the thumbs or fingers of these individuals and no evidence of a lytic, destruc tive 'tive lesion in the feet. have not observed any loss of calcium salt in tha bones of the wrist and remaining bones of the bund and phalanges in any of these individuals, ,^!V and thera has. been no evident sclerosis of the wrist `^^ahdhand bones, . j.. ^ "-2. : Mild stage: The earliest change found in ` ataDoileolysia in these workers has been a loss of the . . cortex of one or more of the tufts of the distal pha- .-t langf^wwith no destruction of the tuft or shaft of y. . r^the distal phalanx.' The next- more advanced stage may be a small, ioAi<iudf-moan cut iB the cortex of the tuft of one or more Aarooftt teynaw*1* yfMStfiwit, MilwiyuMwuiyl'lw wiS | Tettf. CSJluunbhMmiuIn -'** -- * -V-..-' ,-iJ +s-. rsi * '-* ?r - z.-' 2. Mild itigt of ecrooetedyei* with half-moon do* foct of diets! phslanx of mid finger,. 1. AcroosteeJyeii with involvement of distal pholsngee of all Snge - * . -- .. . -- v*Z --.'n V a > .'.'Sii;' -- ;-*?x - J 4 *':v:>L, `fr*- V ` . *V:- H: -.S V^>_T "j. f .. ^ cortex of the-distal phalanx of Z'r V ;' *raid-finger*-*:.j\ v- ^"j.. .. *? .^. . . ; - '' ` ^flCtA^vanced stagat-A mcresevere lytic deatruc- <- -.^ A'."t. j^TQtx.inei; be a cornplcte loss of the tuft and a por- ^-*^T one or snore distal phalanges V r * `^^lurtllvaiiated.in Fig.l;in which the tuft of the distal '^./ ^^>halanx o! the right thumb and the tuft of the distif`phalanx of the left fifth finger are completely . *~.* ^V^^beenVAdditibnally, there may be in the same hand ' ,*vw^. * portion of the- distal rim of the tuft remaining, * loer oi the proximal portion of the tuft and a .portion ofthe shaft of the phalanx, which can also be identified in the remaining phalanges in Fig 1. tThi* rose may be of a transverse nature through the 4. Healing'stager In'thia phase; thank'is often! definite fragmentation-oi the remaining tuft* andofthe filled-in area where the previous destruction* was not^d through the shaft of the distal phalanx; This may goon to a complete bony union or remain-': as a fibrous union with fragmentation- In Fig 3 and' 4, x-ray films of tha same individual well demon strate this. This employee had almost completereunion of the multiple fragments when .first seen in November 1965 and again in November 1966 (Tig 3). In the latter, the completely healed shaft* and tufts of the distal phalanges are indicated by. no* residual fragmentation with fibrous union. There is a definite shortening of the shaft and a widening oi * RSV 0020608 rv*n.-4. V' . **+* 3*~ ^.. ACflOOmOlYSlS-WHSON ET Ai. S' _ ; -r ..'V~Jv'***-*' ^ *-V* . j . .j j^Biiipand tuiV bblh.m the tnncverM'UMi th r liraposterior diaoaetazi'Thie is roost likely due to Table 1-A(i DtotribyPos of Cases .rtombihaucp of constant pressure, and by tbe nor4b.!, of ibo soil tissues, particularly the.ten* . * * iflcegjffibe dirtaLphalange*. f ^.!* ... ` . .Occupational Aspects of Syndrome ,, '5ti' * ` ' *' ' v4af'*vBasedTupon our observations of these. 31 cases, it jgSpappeaa aa'if this syndrome may be of occupational tSi'&rigiirand ie soroche* related to the process of vi- ^.A^Mmyi'thlonde polymerization^ Its specific cause if not ? presently known. W# are performing extensive re- . ..***2^ starch in an effort' to find the cause. Two other parefemng to the condition have appeared in the ^Vvf^I^ifeeture. The publication by Suciu et al* contains r* specific information, and merely alludes to some 'Vwipd' problem; That of Cordier et al* presents case vjt*i.Jaistoriewith symptoms.similar to many of the cases describe. This syndrome differs from idiopathic familial acroostaolysia is that only the hands involved- v.K.,- "** ^ * *' #'*** ** ' Vinyl .Chloride Polymerization Process 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. No cases of acroosteolysis have Seen found bx * these 1,000 persons. - ^ Basically, the manufacture of polyvinyl chloride consists of polymerizing vinyl chloride. The reac-'V, 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, dried9 and sold as a finely divided white powder. ;* ' * The polymerization operations are carried out in.- closed processes and provide little opportunity for; , ^^dtyvinyl^chroridie is a widely used synthetic resin. ip?>,'VX has been manufactured commercially for more 30 7caJ3 and is used in upholstery fabric, floor ~ waU'fOa,Viro insulation, phonograph records, employee exposure. Following the completion of the. polymerization reaction, periodic cleaning of the walls and agitator of the polymerizer is necessary. * The frequency of this cleaning and ita method varies r ^end'inahy-other 'commonly used commodities. For with the type of material used in these vessels and kv^many.oif these usee, the resin (CH-CHCI), is mixed with different manufacturers. The most common <^^th^thejf inateriala.to echieve the desired physical practice has been to accomplish the cleaning man v^charactenstica. The hand syndrome occurs apparent- ually by using hand scraping techniques, with work c^ly.only in those people exposed to vinyl chloride or to ers spending several hours each , day on this, job V^other chemicals used in the manufacturing process assignment. Personnel performing this'job are com- ;^^^f,theraam'ilself or both. In-addition to our exami- monly referred to as "polyclean* H*aUd-SCaroostoJy*U wtth only minor roomfoograpbic cbenfts. ftigftt, lus inQMrtnal one,month sftafrrS.A- a. ACJZ00STE01Y3IS--WILSON rr - - --- vv- 5S1> eraT to some degree through the prolongad/hand . iUempsfed to study the relationship of tbs occurrence of the disease. Twen- c&4.*TB >9* bur 31 cases have either been on the `"`'polycleanar" job uaignment at the time the syn'"drome appeared' or have had that assignment at t*sotoe-time in. the past. This job assignment is the *\nly one showing any positive correlation with the craping-operatione as well aa the occasional use of hammers to remove the residues. In support of the physical insult factor, we have quite recently ob~ served the^effecta of a finger injury to an existing. case of this syndrome. Figure 4 (left) shows an. x-ray film of the left hand of the first of these cases of acroosteolyais (accompanied by Raynaud's symp* toens and akin nodulea on ths dorsal surfaces of the" .* - -r- .-*A* ' i ~v , rr :%..otcurTencen( the syndrome, hands). The bone damage is quite limited. Figure ' tr^ Attack Rpte.--The syndrome has a low attack 4 (right) shows the same hand with the roentgeno-" . ; ' *V.raa.Oui experience indicates it occurs only in leas gram taken four months after a crushing injury to % *'i thajx^%..of all production employees who at one the mid finger, with lysis having resulted to the tuft \ . j * . * V - r^June'have had potydeaning experience. of the distal phalanx. We believe this activity was . % -'7 iz'-'+xX.Xg* Distribution.--The youngest of our cases is stimulated by the trauma. ^ ` w :v r.^Syean old; and the oldest is 47, with the majority Personal idiosyncrasy appears to be an important v-ii t ' - ,v_r faJHsg'in the 30 to 39 age group. The complete dis- factor because of the low incidence of occurrence of "\`T.V.v . ' v' tribution is shown, in Table 2. the disorder. This is especially significant because, .ar.j; JinZFhi appearance of. the syndrome among younger ??vTri.r"employees may be influenced by the fact that the .polycleaning job is one of the initial job assign1**1'r-f*-caents into .which employees in such plants are although all polycleaners are subjected to essentially similar chemical and physical insults, the inri- dence of this syndrome is very low, and the explanation for this can only be made on the basis of person*- * J* *. 'V *:'V -^'Tncubation Period.--If this syndrome is related to ^7.'K'tiOccu`pstional factors, as we believe, then the time ' " M*exposure to these factors should he significant. have investigated the time spent on polyclean* although accurate job-time assignment in- formation is difficult to develop, it appears as if none `i J -of these .cases has had less than 12 months poly- ^Sfcleanmg experience.':. V al idiosyncrasy. We suspect pertinent factors here are related to the individual's vascular system, the nerves controlling the blood supply to the fingers, ; . - and to the specific type of collagen in the intiivid- ual's hands. We are in the process of investigating these factors. We have observed no serious disability in any of these cases. A few have been partially disabled be cause of hand soreness, to the extent that some................ restriction in manual activity was necessary. Im provement in the symptoms, as well at in the roent genological findings, has occurred in. many cases ` ___ . unique and, with the without adequate explanation. * . ./ ' * ^ ; ^exception of'reference* 3 and 4, previously unre- We wish to emphasize that-no cases have, beeri'^l. ;fiftW^ `ciiiordeR.`Tha--specific cause is presently found, after extensive search,' in individuals eithex* *^^^,^_unkhcwn. although it appears to he related to the working with the finished polyvinyl chloride or \ ^^vj&:'maaufiilctuiu' of- vinyl chloride and polyvinyl chlo* copolymers, or in processing the polymer into plastic * ^>^i^ride.'Not only, are the-x-ray findings of themselves products. In these processes, more exposure to:tbfl.:.: "wT'v* hutwhan accompanied by the symptoms of Rayhaud' phenomenon, the syndrome becomes ex- , spe^c*^ far as we are aware, this has not A ^observed .response, to^ any toxicant in any animarspeciea-;Wa-hsve attempted to arrive-' ^C^.^. atan explanation of its.cause, ss well as the physio** olysia of the bands,.or abnormal response .oi.thej ^^^^.logicaTmc^aniam'whereby the extreme specificity hands to cold insult. Any evidence of the' existencej-^vr'^v tbe,-diatal phalanges of -the hands occurs, but of any of these factors should contraindicate the `/S;?^ave.been unsuccessful!. We believe, the condition is signment of. an individual ta r*polycleaningjT: and* ^ rwull^ol'pireellactorsv.' all of which must be ^ forriccufren(t i-chemical-insult^ cynersay Kiss"a. physical,icsuit^afld (3) ia;peronaIidiQ5tncxa5y. ' jyThe ch'ejnical inaultcould occur from one or more of - * iL^^'^^amonoiiiers^.cftJalyBt^ end intermediate reaction , iK*C^v^^rp<^c^e^^^in.polyinerixerv A.low degree of * . ^^^exposura wthe*e<^d^tnjj ^ with the* , w- 7 ^ wt^eTP*r*,'` - 's. U sikKiW .cutaheouslsrjor'bv-inhaletibn^ Research studies arw .^"lawii^vkiior Prsdi-- .de Qenn 6m Vkai:!}f*diJiu*m