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Palm Thorns as a Cause of Joint Effusion in Children

1953; Radiological Society of North America; Volume: 60; Issue: 4 Linguagem: Inglês

10.1148/60.4.592

1527-1315

Rolla G. Karshner, W Hanafee,

Orthopedic Surgery and Rehabilitation

Palm thorns may be the basis of obscure joint effusions in children. Between the years 1946 and 1951, 7 cases of joint effusion due to this cause were seen in the Children's Hospital, Los Angeles. A review of the literature since 1927, however, failed to reveal any similar example. The offending tree in California is the date palm (Phoenix dactylifera, Phoenix roebelenii, Phoenix canariensis) (Fig. 1). This tree grows throughout the South in areas which do not have frost . Thorns from any of the many varieties of century plant (Agave americana) could conceivably produce the same picture, but we have not encountered these in the joints, though they have been seen in the soft tissues. The palm thorn is particularly treacherous because the tip dries out much faster than the main body of the thorn and is prone to break off. The distal 1.5 to 3.0 cm. becomes sharp, hard, and brittle, showing an abrupt change in color and flexibility. It is easy to see how this needlelike tip could become embedded in soft tissues and be disregarded as a “scratch,” or how the main portion of the thorn could be removed and the point left unnoticed and forgotten. The majority of our patients were approximately six years old at the time of the injury (Table I). The interval from that time to admission to the hospital ranged from seven days to two and a half years. The informants were usually the parents. In some instances, a history of palm thorn injury was elicited only upon the most careful questioning. Even with this, a puncture wound was denied in two cases. In all but one of the remaining five, the thorn was thought to have been removed. Close co-operation between the radiologist and clinician facilitates the diagnosis of palm thorn injury. The roentgen picture reveals soft-tissue swelling and joint effusion without bone involvement (Fig. 2). In only one of our cases was there no roentgen evidence of disease. The thorns are not radiopaque. Joint effusion due to palm thorn may be differentiated from tuberculosis and fungus infection by the history of injury, lack of infectious contact, negative tuberculin and coccidioidin skin tests, and the absence of bony involvement as demonstrated on the roentgenogram. It is obvious that pyogenic arthritis may result from the entry of a palm thorn into a joint, and that both conditions could thus be present simultaneously. One may suspect an underlying palm thorn in the presence of prolonged joint swelling and a lack of response to antibiotics. In such instances a positive history is most helpful. Inasmuch as the palm thorn will be found in only a single joint, diseases which affect multiple joints, such as rheumatoid arthritis, bacteremia, allergic arthritis and Clutton's joints, are easily excluded. Specific clinical findings also accompany these disorders. The roentgenographic demonstration of bony changes in osteochondritis dissecans and fractures are in themselves diagnostic.