05/08/2021 at 12:05 am #17635Xue HengParticipant
This case was asked by one of my frineds.
I cannot confidently answer her, so I turn you for help.
This was a patient with wrist pain.
He used to have elevated uric acid, but the level of uric acid now is within normal range.
There was no other positive history.
What is the hyperechoic lesion superficial to the pisiform?
Is it crystal deposition? Is the crystal deposition visible on X-ray?
Thank you, Steve.
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05/08/2021 at 11:42 am #17669Stephen BirdKeymaster
The history of gout makes me think of gout immediately, however the x-ray appearance is a bit atypical I think.
I had a case yesterday of gout in the peroneal tendons around the ankle and it caused a dense acoustic shadow on the ultrasound but it was still not that obvious on the plain radiograph.
I think generally monosodium rate is not that dense on a plain radiograph.
I will add that case to the case of the week section so you can take a look.
The density of the calcification is much more in keeping with hydroxyapatite and so I am wondering if it is a calcific periarthritis where there is hydroxyapatite within the joint capsule.
I also think it is possible that the hydroxyapatite is within the FCU tendon and this would be painful.
Looking at your images I am not absolutely sure if the hydroxyapatite is within FCU itself or beneath it within the joint capsule.
The other crystal which could be considered is CPPD, however I think this is less likely given the location and appearance on imaging.
So in balance with the ultrasound and the plain radiograph appearances I favour hydroxyapatite within the joint capsule of the pisotriquetral articulation or directly within the FCU tendon.
06/08/2021 at 12:02 am #17697Xue HengParticipant
Thank you, Steve.
The accurate diagnosis is never easy.
We have to take all the known into consideration, and balance the results of various imaging modalities.
Just like what you taught me. And then to find out the most possile answers.
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