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= Dieterich's Disease = Dieterich’s disease, also known as avascular necrosis of the metacarpal hand, is an extremely rare condition characterized by temporary or permanent loss of blood supply to the metacarpal head of the metacarpal bone, resulting in loss of bone tissue. The five metacarpal bones are long bones located between the carpals of the wrist and phalanges of the fingers. Collectively, the metacarpals are referred to as the "metacarpus." The metacarpals are important in maintaining grip strength and mobility of the fingers.

Dieterich's disease is often confused with Mauclaire disease, which is characterized by symmetrical flattening of all metacarpal heads. In the case of Dieterich's disease, some but not all metacarpal heads are affected. Onset of this disease can be attributed to steroid usage, systemic lupus erythematosus, or trauma. In some cases, it is randomly-occurring. This condition was first described by German doctor H. Dieterich in 1932 in his journal entitled "Die subchondrale Herderkrankung am Metacarpale iii," translating to mean "The subchondral focal disease on metacarpal III," in English.

Dieterich's disease can be diagnosed through medical screening or blood testing. Physicians may also diagnose Dieterich's disease by taking a history of the patient's symptoms.

Cause
The cause of Dieterich’s disease is still not fully understood. The disease can afflict patients of any age, but typically affects patients in their 30's. Though rare, it can also occur in children. Statistics show that generally more men are affected by Dieterich's than women in an estimated ratio of 3:2. The third (middle finger) metacarpal head has been reported to be the most common site of necrosis. Though osteonecrosis is a fairly common condition, many cases of avascular necrosis of the metacarpal hand go without being diagnosed. This is because presentation of symptoms is variable depending on the patient. Sometimes, the patient may even choose to ignore their symptoms.

Onset of Dieterich's disease can possibly be attributed to steroid usage, trauma, systemic lupus erythematosus, renal transplant, or scleroderma. It can also afflict patients living with congenital short digits or atypical anatomical epiphyseal blood supply. In some cases, however, Dieterich's disease can occur spontaneously.

Some risk factors include:


 * Radiation treatments
 * Alcohol abuse
 * Autoimmune disease
 * Blood disorders

Despite the number of possible risk factors and causes of Dieterich's disease, no single item has been determined as the primary cause yet.

Symptoms
Early on, symptoms may not be noticeable. Patients may either be asymptomatic or may experience progressive joint collapse with increased pain and increasingly restricted range of motion.

Some symptoms that patients affected by Dieterich's disease may experience include:


 * Dull joint pain
 * Swelling of joint
 * Limited range of motion
 * Tender joint upon palpation

Symptoms of Dieterich's disease may be incorrectly attributed to other bone conditions or medical issues such as rheumatoid arthritis, gout, or osteoarthritis.

Diagnosis
Diagnosis of Dieterich's disease can be done through x-ray imaging, magnetic resonance imaging (MRI), biopsy, or computed tomography scan (CT). Scans showing bone tissue will typically display flattening or collapse of the metacarpal head, or deterioration of cartilage in the joint.

In some cases, a physician may take a patient history and make a diagnosis based on a combination of medical imaging and symptom history.

Dieterich's disease can be characterized by swelling, which can be indicated by C-reactive protein (CRP) and normal erythrocyte sedimentation rates (ESR), both of which can be shown in a blood investigation.

Unnamed 54-year old female
An unnamed female was seen by Belgian doctors for a swollen, painful third metacarpophalangeal joint. According to the patient, these symptoms had persisted for 3 months with no previous recorded trauma. She had been taking large doses of cortisone to treat lung disease due to smoking. Though the patient could fully extend the joint, flexion was limited. Radiographs revealed deterioration of cartilage and collapse of the metacarpal head. The patient was unsuccessfully treated with anti-inflammatory drugs, then treated with removal of necrotic bone and bone grafting surgery with fair success.

Unnamed 37-year old male
A 37-year old male was seen by Chinese hand-surgery specialists for chronic dull pain in his right hand. Physical examination showed swelling in his third and fourth metacarpophalangeal joints, and there was significantly limited range of motion on the third metacarpophalangeal joint. Patient had no history of trauma, but may have been affected by his work as a mechanical laborer. He had been seen one year previously and magnetic resonance imaging revealed flattening of the fourth metacarpal head. The patient returned because of continued pain. The third metacarpal head was then treated through bone grafting. In a follow up, it was noted that pain and swelling had diminished and there was a noted improvement in range of motion of the third metacarpophalangeal joint.

Unnamed 16-year old male
A 16-year old teenage male was seen for sudden pain in his right metacarpophalangeal joints. Though there was no history of trauma, the patient was a manual laborer. Range of motion was slightly limited and joint was mildly swollen and tender when palpated. Patient was originally treated with splinting and ibuprofen, but this further worsened his condition. Patient was then treated with physical therapy, but symptoms persisted. Finally, patient was treated with bone grafting surgery and splinted for three weeks. After surgery followed by physical therapy, full range of motion was restored within eight weeks.

Unnamed 36-year old male
A 36-year old male electrician with no past history of trauma presented with a painful right middle finger metacarpophalangeal joint. Range of motion was not limited. The afflicted joint did not have any particular outwardly visible indicators of Dieterich's disease besides some crackling noises with movement. Patient would stretch his finger for temporary relief. In this case, though blood work and plain-film imaging did not show any abnormalities, an MRI showed avascular necrosis in the middle finger. The patient was successfully treated with physical therapy.

Unnamed 68-year old woman
A 68-year old woman was first seen with pain attributed to either inflammatory or septic arthritis. She had been receiving orthopedic treatment previously due to increasing pain. The afflicted metacarpal head of the ring finger showed limited range of movement and chronic swelling. Through laboratory testing and based on the evolution of the pain, it was determined to be Dieterich's disease. The patient was initially suggested surgical treatment, but she rejected surgery due to acceptable functional status of the joint.

Treatment
Before treatment, healthcare providers take into account the age of patient, amount of affected bone tissue, and cause of symptoms. No single method of treatment has been determined as the optimal treatment yet, as each case is extremely variable.

Some possible treatments include:


 * Anti-inflammatory medications, such as analgesics
 * Splinting
 * Splinting involves immobilization of a joint in effort to reduce swelling and provide stability. Generally, splinting is only a short-term solution. Excessive use can result in worsened stiffness. Joints can be splinted using tape, aluminum, plaster, etc.
 * Bone grafting surgery
 * Bone grafting surgery involves the transplant of bone tissue in effort to fix bones damaged by injury. This procedure may fill an area where bone tissue has necrosed and help provide new stability to the joint.
 * Joint replacement
 * Joint replacement surgery replaces parts of damaged joint with metal, plastic, or ceramic devices. These devices are called prostheses, and help replicate the movement of a health joint.
 * Physical therapy
 * A physical therapist may provide a plan of treatment aimed at improving strength, functionality, and mobility of the metacarpophalangeal joint afflicted by pain and limited range of motion attributed to Dieterich's disease. These treatments may include manual therapy or therapeutic exercises.