0:01

The first case I'm going to show is an interesting one.

0:04

It is a 52-year-old woman, uh, without a history

0:09

of trauma with long side, long standing, ulnar sided

0:13

wrist pain and swelling

0:16

and discomfort at the base of her thumb.

0:20

Sadly, I do not have the conventional radiograph,

0:22

but it is an MR course.

0:23

So we'll stay with MR for now.

0:26

And I've got, uh, again, my most favored nation projection.

0:30

The Corona projection for the wrist, uh, T one on the left,

0:33

proton density, fat suppression,

0:36

spare a special in the middle,

0:38

and then a 3D gradient echo with fat suppression

0:43

and contrast, uh, on the right, a thin section image.

0:47

And I think, uh, let's, let's demystify

0:49

and dem magnify a little bit so it's not, uh,

0:53

too much anatomy all at one time.

0:56

And once again, on the dorsal aspect of the wrist,

0:58

you can see the sideways V

1:01

and very nicely see the long, um, dorsal, um,

1:06

radio lu NATO triquetral ligament.

1:09

And there's the transverse carpal ligament.

1:11

And then we get into the vola aspect and,

1:14

and we're able to see the short portions of the arcuate

1:17

and some longer portions of the deltoid ligament.

1:21

Now, what I'm sure you're struck by is the swelling,

1:24

which you would have to be, um, on your fourth pint

1:27

of Woodford Reserve bourbon to miss this.

1:30

Uh, there's tremendous swelling

1:33

and capsules, uh, synovial thickening around the first CMC,

1:38

despite the absent history of trauma

1:41

and the relative paucity of arthrosis elsewhere.

1:44

We don't have her carpal metacarpal

1:47

joint, uh, on this image.

1:49

But then in concert with that, we've got these very

1:53

impressive penetrating cystic erosions

1:56

and pseudocysts, um, in the, in the absence of,

2:00

of really abutment signs.

2:02

There's no positive ulnar variance.

2:04

Uh, sure there are some changes in the triquetrum,

2:07

which we commonly see pitting in that area anyway,

2:10

and there's very little in the way of, uh, perforation

2:14

or erosive change of the lunate.

2:16

So, you know, what's, what's a mother to do at this point?

2:19

Um, we, we don't have a history of instability,

2:22

and we are talking, uh, TFC

2:25

and the TFC itself shows some minimal signal,

2:28

which we do see with advancing age.

2:31

So you have to be very circumspect about

2:33

how you assess the triangular fibrocartilage in people over

2:37

the age of 50 to avoid, uh, over management.

2:41

Uh, so this is a patient with an inflammatory process, uh,

2:46

but when we look at the anatomy of the first CMC,

2:50

we're missing a few ligaments here.

2:52

Even though this isn't the ligament section,

2:54

we're missing both the superficial

2:56

and deep anterior oblique ligament of the thumb,

2:58

thumb, what's happened to it?

3:00

It's been digested.

3:01

And we also have this little funny little fragment here

3:04

that's getting trapped, which is sitting on the dorsal side

3:07

of the thumb, and it is kind of flopped

3:09

around another fosbury flop.

3:12

And it's interposing itself

3:14

between the greater angular in the base of the first.

3:17

So the Dorsey radial ligament is also torn.

3:20

So this is an unstable, uh, situation.

3:23

And in a woman, uh, with this combination of TFC

3:28

and first CMC, which ous inflammation, you have

3:31

to at least wonder about a, a crystalline disorder such

3:36

as CPPD, which is calcium pyrophosphate deposition,

3:41

uh, uh, disorder dihydrate, or disease dihydrate.

3:45

So it really should be CPP dd, uh,

3:49

to describe it, uh, appropriately.

3:51

Um, you also got very heterogeneous signal internally,

3:56

which would support that diagnosis.

3:58

Now, what are some other things

3:59

that we might be looking for?

4:01

Triangular fibrocartilage disease with calcium here,

4:04

we don't have the, the plain film,

4:06

but there certainly is evidence of ulnar cited disease.

4:09

These patients can get metacarpal involved,

4:12

and sometimes they'll get some hook shaped osteophytes.

4:15

Now this patient is interesting in

4:18

that she has known hyperparathyroidism.

4:21

Her calcium is 12.8, uh, which is fairly high,

4:25

and her chief complaint was not her hand,

4:28

her chief complaint was fatigue,

4:31

and I suspect that that fatigue was related to,

4:34

to her hypercalcemia.

4:37

Uh, what else can we see in, in, uh, uh,

4:39

pyrophosphate deposition?

4:41

As we discussed earlier, we can see a charcoal like picture.

4:44

We can see an osteoarthritic picture,

4:46

we can have metacarpal involvement, we can have

4:49

capitate involvement, we can have lunate involvement, um,

4:53

and we can have trica involvement.

4:55

In this case, we, we don't have much trica involvement,

4:58

maybe just a smidge.

5:00

Uh, and there is tremendous enhancement, uh,

5:03

of the intraarticular space more than you would expect

5:06

for somebody with just simple DJD of the first CMC.

5:10

So this is a hyperparathyroidism case with,

5:14

with a pyrophosphate disorder affecting two major

5:17

articulations, the, the ulna and the first CMC.

5:21

Any comments about this one,

5:22

Don? Yeah, uh, uh,

5:23

a couple comments.

5:24

Uh, as you probably know,

5:26

calcium pyrophosphate disease is my favorite disease

5:29

to, uh, talk about.

5:31

And, uh, some people maybe in the audience have heard,

5:35

have heard me talk about, uh,

5:37

the target area approach to arthritis.

5:40

Uh, and the wrist is one of the joints where I use it,

5:43

and I look at a radiograph or CT or mr

5:47

and I try to decide what compartments of the wrist

5:50

that are that are involved.

5:52

So when, when I see, uh, selective

5:55

or significant involvement

5:57

of the first carpal metacarpal joint,

6:00

which is the dominant abnormality here, there's about four

6:04

or five diseases that that come to mind.

6:06

The, the most common ones, of course,

6:08

we see are osteoarthritis, osteo aosis,

6:11

or inflammatory osteoarthritis.

6:14

Uh, but you know, generally you're not gonna see all

6:18

of the changes that we see in a case like this.

6:21

Uh, in those cases, the trife portion

6:23

of the mid carpal compartment may be involved.

6:26

Crystal deposition disease, be it pyrophosphate

6:29

or gout, also can involve the radial aspect of the wrist.

6:33

Uh, and so that it would be another consideration,

6:37

which apparently is accurate in this particular, uh, case.

6:41

And, and, uh, I, you know,

6:44

pyrophosphate arthropathy certainly can be very, very severe

6:48

and lead to subluxations,

6:50

but the are two other points I would make.

6:51

The patient has hyperthyroidism associated with CPPD

6:56

and the paraform produces ligament laxity.

6:59

And so part of the subluxation may be the effect of, uh,

7:03

the parathyroid hormone elevation

7:06

and then the final disease.

7:08

And unfortunately, when you showed me this earlier,

7:11

I was gonna try to find it,

7:12

but I don't have it on my computer.

7:14

It is in selectively involves the first carpal metacarpal

7:19

compartment is scleroderma,

7:21

and why it involves that compartment.

7:23

I do not know. Some

7:24

of the cases will show massive calcification,

7:28

hydroxyapatite calcification in and around the joint,

7:32

but the, the, I would just have you remember that,

7:36

that would be in the differential for this,

7:39

not the correct diagnosis,

7:40

but severe destructive arthropathy

7:44

of the first carpal metacarpal joint scleroderma, uh,

7:47

is also on my list.

7:50

Well, this case, you know, is, is probably secondary

7:53

to hyperparathyroidism,

7:54

and you can get it with, I think hypomagnesemia,

7:58

I think it's called gitelman's.

7:59

Yeah, Gitelman Getman

8:01

Syndrome. Yeah. And

8:02

a few other endocrinologic uh, abnormalities, some

8:06

with looser association, some with a, some

8:09

with a tighter association.

8:10

I think hypophosphatasia is one with a,

8:12

with another tighter, uh, association.

8:15

Um, and,

8:16

and this, would you describe this,

8:18

the patient had pseudo gout.

8:19

Would you describe this as tophaceous pseudo gout?

8:23

Yeah, so Tophaceous pseudo gout is,

8:27

is a name introduced in literature a number of years ago

8:30

for mass, like deposits composed not of urate crystals,

8:34

but of pyrophosphate crystals.

8:37

And I guess extending that definition,

8:40

you could say here would be great to have a radiograph.

8:43

I'm curious if some of this is calcified around here.

8:46

I, I can't tell that,

8:47

but yeah, this could be, uh, classified as that.

8:50

But the, the, the most characteristic findings

8:54

that I've seen with tophaceous pseudo gout are soft tissue

8:57

masses eroding in the bone.

9:00

Okay. Shall we move on to the next.