Diagnostic and Interventional Imaging (2015) 96, 115—119

E-QUID: ANSWER / Musculoskeletal imaging

Osteoarthritis and scapholunate instabilityin chondrocalcinosis�

M. Kahlounea,∗, X. Liboutonb, P. Omoumia, A. Larbia

a Radiology Department, Saint-Luc University Hospitals, av. Hippocrate 10, 1200 Brussels,Belgiumb Orthopedic and Trauma Surgery Department, Saint Luc University Hospitals, av. Hippocrate10, 1200 Brussels, Belgium

Observation

A 71-year-old man was referred by his general practitioner for an orthopedic surgery consul-tation for intermittent pain on the radial side of the right wrist with swelling which haddeveloped over 18 months despite no history of trauma. His history included a fracture of

the distal end of the left radius operated on about 12 years previously. Clinical examinationfound moderate limitation of movement and pain on palpation of the radial side of thewrist. X-ray images of the right wrist (Fig. 1) and a non-contrast-enhanced CT scan of bothwrists (Figs. 2 and 3) were available, obtained before the consultation.

DOI of original article: http://dx.doi.org/10.1016/j.diii.2013.08.016.� Here is the answer to the case ‘Wrist pain’ previously published. As a reminder we publish again the entire case with the response

following.∗ Corresponding author.

E-mail address: merouane.kahloune@uclouvain.be (M. Kahloune).

2211-5684/$ — see front matter © 2014 Published by Elsevier Masson SAS on behalf of the Éditions françaises de radiologie.http://dx.doi.org/10.1016/j.diii.2013.08.017

116 M. Kahloune et al.

Figure 1. AP X-ray image of the right wrist.

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igure 2. Coronal CT slice of the right wrist.tntslntcOis

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igure 3. Coronal CT slice of the left wrist.

hat is your diagnosis?

rom the observations, what would your diagnosis be frommong the following?gout;rheumatoid arthritis;SLAC wrist combined with chondrocalcinosis;hydroxyapatite.

iagnosis

capholunate advanced collapse (SLAC) of the wrist associ-ted with chondrocalcinosis.

omments

he AP X-ray image of the right wrist (Fig. 4) shows patho-ogical scapholunate diastasis, a scaphoid in flexion with itsubercle visible (cortical ring sign — white arrows), severearrowing of the radioscaphoid joint space, narrowing ofhe lunocapitate joint space (black arrows). The CT coronallices of the two wrists show, on the right (Fig. 5), patho-ogical scapholunate diastasis, severe right radioscaphoidarrowing with subchondral osteosclerosis (arrows), and onhe left (Fig. 6), pathological scapholunate diastasis and cal-ifications of the triangular fibrocartilage complex (arrow).n the left side (Fig. 7), multiple cysts can also be seen

n several carpal bones (arrows) and calcifications in thecapholunate space.

iscussion

LAC (scapholunate advanced collapse) wrist is osteoarthri-is secondary to a lesion of the scapholunate ligament,hich, in the long term, induces scapholunate dissociation

Osteoarthritis and scapholunate instability in chondrocalcinosis 117

Figure 4. AP X-ray image of the right wrist: scapholunate diastasiswith flexion of the scaphoid (‘cortical ring sign’ of the scaphoid

Figure 6. Coronal CT slice of the left wrist: pathological scapholu-n(

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tubercle visible — white arrows), severe radioscaphoid narrowingand narrowing of the lunocapitate joint space (black arrows).

combining flexion of the scaphoid, dorsal inclination ofthe lunate, and a pathological scapholunate diastasis(> 2.5 mm). The scapholunate ligament is the most impor-tant intrinsic ligament of the wrist, because it is the mainstabilizer of the first row of carpal bones. The origin of

SLAC is often traumatic, more rarely degenerative. It isthe most common form of osteoarthritis of the wrist typi-cally evolving in three stages, at the beginning affecting thespace between the radial styloid process and the scaphoid,

Figure 5. Coronal CT slice of the right wrist: pathologicalscapholunate diastasis, severe right radioscaphoid narrowing withsubchondral osteosclerosis (arrows), fine calcifications in thescapholunate space and opposite the head of the capitate bone.

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ate diastasis, calcifications of the triangular fibrocartilage complexarrow) and in the scapholunate space.

hen the radioscaphoid joint space, and finally at a moredvanced stage, the lunocapitate space [1].

Chondrocalcinosis or calcium pyrophosphate dihydrateCPPD) crystal deposition disease has been described aseing one of the main causes of SLAC [2,3]. It is a micro-rystalline arthropathy related to the deposition of CPPDrystals in the articular (cartilage, fibrocartilage) and peri-

rticular (synovial membrane, capsule, bursa, ligament,endon) structures. This condition occurs sporadically afterhe age of 50, predominantly in women. Familial forms are

igure 7. Coronal CT slice of the left wrist: multiple cysts in sev-ral carpal bones (arrows) and calcifications in the scapholunatepace.

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xceptional and commence between the ages of 20 and 40the ANKH gene) [4]. Secondary forms should be consideredn cases where onset occurs before 50 years of age, sinceere chondrocalcinosis may be associated with hemochro-atosis, hyperparathyroidism or hypomagnesemia. Patientsay be totally asymptomatic. Symptomatic forms appear

n half of the cases as pseudo-osteoarthritis with symmet-ical, bilateral, acute flare-ups, and in a quarter of casess pseudogout, which can mimic septic arthritis. The mainoints affected are the knee, wrist, pubis, hip and shoul-er.

In the wrist, SLAC is a common but late complica-ion of chondrocalcinosis. In all cases of SLAC, apart fromhere there is a history of trauma, the presence shoulde sought of calcifications at the intercarpal joints or inhe triangular fibrocartilage complex — the most commonnd most specific signs, but which are sometimes absentn standard X-ray images. The sensitivity of radiographsor detecting calcifications is indeed only 40 to 50% [5].solated narrowing of the STT (scaphotrapeziotrapezoid)oint with bands of subchondral osteosclerosis is also veryuggestive of a diagnosis of chondrocalcinosis [6]. The pres-nce of metacarpophalangeal osteoarthritis (particularlynd and 3rd MCP) with hook-like osteophytes, points stronglyowards chondrocalcinosis secondary to hemochromatosis7]. Ultrasonography is more sensitive than standard X-ay images for detecting calcifications when they exist [8].ith ultrasound, CPPB deposits may appear as a hypere-

hoic band parallel to the surface of the hyaline cartilager as hyperechoic spots in the fibrocartilage and tendons.odular or oval deposits may also be seen in the bur-ae and articular recesses [9]. Even though the CT scans still not used much in this indication, its high resolu-ion can detect the presence of articular and periarticularPPB crystals [8]. It could be offered, according to thelinical picture, in a case where X-ray images are nega-ive and CPPB crystals are not seen with ultrasound. From

CT arthrogram of the wrist, the scapholunate ligamentnd the triangular fibrocartilage complex, which are oftennterrupted by the destruction, can be studied, and abovell, the state of the articular surfaces can be assessed10].

Romano (in 2003) described a particular form ofhondrocalcinosis that he called SCAC (Scaphoid Chondro-alcinosis Advanced Collapse) wrist, developing through

stages similarly to SLAC and SNAC wrist, but with spe-ial features, namely impaction of the scaphoid intohe radius, frequent absence of scapholunate diasta-is and sometimes the presence of isolated mediocarpalsteoarthritis.

tage 1

solated involvement of the radioscaphoid joint sometimesith narrowing and subchondral densification.

tage 2

lear radioscaphoid involvement with narrowing of the jointpace, verticalization of the scaphoid which is impacted

M. Kahloune et al.

nto the radius. Lunocapitate narrowing. No scapholunateiastasis.

tage 3

ediocarpal dislocation; the scaphoid is completelympacted into the radius in a manner which would be unusualor a SLAC or SNAC wrist.

tage 4

arer, seen as destruction of all the carpal joints with par-icular involvement of the radiolunate joint.

The treatment of osteoarthritis of the wrist linkedith chondrocalcinosis is usually conservative, basedn non-steroidal anti-inflammatory drugs, colchicine andmmobilization during flare-ups. Rarely, distal resection maye indicated of the scaphoid, in the case of scaphotrapezoidsteoarthritis, or even scaphoidectomy with arthrodesis ofhe 4 medial carpals [11].

onclusion

n the first instance, the presence of a SLAC wrist in thebsence of trauma suggests chondrocalcinosis, even if thealcifications are not visible on X-ray images.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

eferences

[1] Kirk Watson H, Frederick LB. The SLAC wrist: scapholunateadvanced collapse pattern of degenerative arthritis. J HandSurg 1984;9A:358—65.

[2] Chen C. Scapholunate advanced collapse: a common wristabnormality in calcium pyrophosphate dihydrate crystal depo-sition disease. Radiology 1990;177:459—61.

[3] Resnick D, Niwayama G. Carpal instability in rheumatoid arthri-tis and calcium pyrophosphate deposition disease. Ann RheumDis 1977;36:311—8.

[4] Hirose J, Ryan LM, Masuda I. Up-regulated expression of carti-lage intermediate-layer protein and ANK in articular hyalinecartilage from patients with calcium pyrophosphate dihy-drate crystal deposition disease. Arthritis Rheum 2002;46:3218—29.

[5] Abreu M, Johnson K, Chung CB, et al. Calcification in cal-cium pyrophosphate dihydrate (CPPD) crystalline deposits inthe knee: anatomic, radiographic, MR imaging, and histologicstudy in cadavers. Skeletal Radiolol 2004;33:392—8.

[6] Saffar P. Chondrocalcinosis of the wrist. J Hand Surg Eur2004;29(5):486—93.

[7] Mrabet D, Zouch I, Sahli H, Fendri L, Chéour E, Meddeb N, et al.Les manifestations ostéoarticulaires de l’hémochromatose.Tunis Med 2011;89(12):891—5.

[8] Magarelli N, Amelia R, Melillo N, Nasuto M. Imaging of chon-drocalcinosis: calcium pyrophosphate dihydrate (CPPD) crystaldeposition disease — imaging of commun sites of involvement.Clin Exp Rheumatol 2012;30(1):118—25.

osis

Osteoarthritis and scapholunate instability in chondrocalcin

[9] Frediani B, Filippou G, Falsetti P, Lorenzini S, Baldi F, AcciaiC, et al. Diagnosis of calcium pyrophosphate dihydrate crys-tal deposition disease: ultrasonographic criteria proposed. AnnRheum Dis 2005;64(4):638—40.

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10] Romano S. Arthrose non traumatique du poignet : la chondro-calcinose. Chir Main 2003;30:285—92.

11] Saffar P. Évolution et traitement de l’arthrose du poignet. E-memoires Acad Nat Chir 2012;11(2):025—30.