title: Knuckle cracking: secondary hyperparathyroidism and what your mother did not tell you.
abstract: BACKGROUND
  Secondary hyperparathyroidism in end-stage renal disease patients has protean musculoskeletal manifestations. Some of our dialysis patients spontaneously vocalized that they had lost the ability to crack their knuckles and then experienced gratifying restoration after surgical parathyroidectomy. We propose that the physiology and mechanical basis of knuckle cracking would be affected by parathyroid-related mineral and bone disorders.
  
  
  RESULTS
  We surveyed all of our chronic dialysis outpatients who had undergone surgical parathyroidectomy. Thirteen (∼12% of the population) individuals were identified: eight males, age 37.7 ± 12.5 years old, dialysis duration of 10.2 ± 7.0 years and peak preoperative intact parathyroid hormone (PTH) levels of 2344 ± 900 pg/mL. Seven patients had no recollection of knuckle cracking issues, with surgery as remote as decades. Six individuals were able to provide adequate histories: four had postoperative restoration of knuckle cracking and expressed great satisfaction from the emotional relief from what appeared to be habitual knuckle cracking. Two of these patients reported rapid return of cracking, occurring in less than ∼2 weeks.
  
  
  CONCLUSIONS
  This is the first report of loss of knuckle cracking due to hyperparathyroidism and its cure in 67% of patients, following surgical parathyroidectomy. We propose that parathyroid (e.g. calcific) changes in articular structures (tendons, ligaments) cause reduced elasticity, limited joint surface separation upon flexion, attenuation of cavitation and thus, loss of the audible crack upon vacuum collapse. The psychological 'release' from habitual knuckle cracking may be a motivator from some patients to adhere to complex parathyroid regimens or to pursue surgical intervention.
authors.affiliation: Division of Nephrology, Hypertension and Renal Transplantation , University of Florida, Gainesville, FL , USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Ross
authors.affiliation: Division of Nephrology, Hypertension and Renal Transplantation , University of Florida, Gainesville, FL , USA.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Paugh-Miller
authors.affiliation: University of Florida Shands Hospital , Gainesville, FL , USA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Nappo
keywords: hyperparathyroidism; parathyroidectomy; renal osteodystrophy