Bilateral wrist pain • Xray of the Week
72 y.o. male presented with chronic bilateral wrist and hand pain. What is the diagnosis?
Figure 1. Bilateral frontal hand and wrist radiographs.
Figure 2. Right wrist radiograph. There is obliteration the radiocarpal joint between radius and scaphoid (red arrow). There is scapholunate advanced collapse (SLAC) with scapholunate dissociation and marked proximal migration of the capitate (green arrow). Deformity of the scaphoid and distal radius (red arrow) is due to remodeling related to the arthropathy. Note the radioulnar joint is relatively spared and there is no chondrocalcinosis in the joints or in the triangular fibrocartilage.
Figure 3. Left wrist radiograph. There is obliteration the radiocarpal joint between radius and scaphoid (yellow arrow). There is scapholunate advanced collapse (SLAC) with scapholunate dissociation and marked proximal migration of the capitate (green arrow). Deformity of the scaphoid and distal radius (red arrow) is due to remodeling related to the arthropathy. Note the radioulnar joint is spared and there is no chondrocalcinosis in the joints or in the triangular fibrocartilage.
Scapholunate Advanced Collapse (SLAC wrist) is due to advanced injury of the scapholunate and volar radioscapholunate ligaments which may lead to rotatory subluxation of the scaphoid and scapholunate dissociation. As in this severe case, the capitate may migrate proximally into the widened scapholunate space and articulate with the distal radius. CPPD crystal deposition disease and trauma are the major causes of SLAC wrist.
Calcium Pyrophosphate Deposition Disease (CPPD Arthropathy) has the same appearance as degenerative joint disease (DJD) demonstrating sclerosis,
joint space narrowing, and osteophyte formation. However, it tends to affect joints which are usually not seen with degenerative joint disease such as the radiocarpal joint, elbow, or restricted to the patellofemoral compartment of the knee. The distribution tends to be symmetric. Chondrocalcinosis is not always seen radiographically despite the presence of calcium crystals in the joint, and subchondral cysts may be prominent.
Treatment options for advanced cases of SLAC wrist include partial fusion such as four-corner arthrodesis, or complete wrist arthrodesis, scaphoidectomy, proximal row carpectomy (PRC), denervation, and radial styloidectomy.
1. Resnick D, Niwayama G, Goergen TG, et-al. Clinical, radiographic and pathologic abnormalities in calcium pyrophosphate dihydrate deposition disease (CPPD): pseudogout. Radiology. 1977;122 (1): 1-15
2. Helms CA, Vogler JB, Simms DA, et al. CPPD crystal deposition disease or pseudogout. RadioGraphics 1982; 2 (1); 40-52
3. Brower AC, USNR DJFMDCDRMC. Arthritis in Black and White. Saunders. ISBN:1416055959. Read it at Google Books - Buy it on Amazon
4. Saffar P. Chondrocalcinosis of the wrist. Journal of hand surgery (Edinburgh, Scotland). 29 (5): 486-93.
5. Resnick D, Utsinger PD. The wrist arthropathy of “pseudogout” occurring with and without chondrocalcinosis. Radiology 1974; 113:633-641.
6. Chen C, Chandnani VP, Kang HS, Resnick D, et-al. Scapholunate advanced collapse: a common wrist abnormality in calcium pyrophosphate dihydrate crystal deposition disease. Radiology. 1990;177 (2): 459-61.
7. Doherty W, Lovallo JL. Scapholunate advanced collapse pattern of arthritis in calcium pyrophosphate deposition disease of the wrist. J Hand Surgery. 1993;18(6):1095-1098
8. Merrell GA, McDermott EM, Weiss AP. Four-corner arthrodesis using a circular plate and distal radius bone grafting: a consecutive case series. J Hand Surg Am. 2008;33 (5): 635-42.
9. Steinbach LS, Resnick D. Calcium pyrophosphate dihydrate crystal deposition disease revisited. State of the Art. Radiology. 1996;200:1-9.
Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of Staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.
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Steven Kussman, MD is a Musculoskeletal Radiologist at Renaissance Imaging Medical Associates in Los Angeles, California. After completing an undergraduate degree in Biology and graduating Magna Cum Laude at Brown University, he went on to Medical School at Boston University. Dr. Kussman was selected to the become a member of the prestigious Alpha Omega Alpha Honor Medical Society in 2008 and graduated Magna Cum Laude in 2009. He was Chief Radiology Resident at Boston University and completed his radiology residency at Boston University in 2014. Following residency, Dr. Kussman then did a one year fellowship in Musculoskeletal Imaging at UC San Diego in 2014-2015.
Dr. Kussman's publications can be found here. He lives in Los Angeles with his wife and son and in his spare time loves to play and watch sports.