Publish in this journal
Journal Information
Vol. 15. Issue 6.
Pages e140-e141 (November - December 2019)
Download PDF
More article options
Vol. 15. Issue 6.
Pages e140-e141 (November - December 2019)
Images in Clinical Rheumatology
Full text access
Mixed crystal arthropathy of the wrist: The contribution of imaging in the diagnostic approach
Artropatía cristalina mixta de la muñeca: la contribución de la imagen en el enfoque diagnóstico
Nikita Khmelinskii
Corresponding author

Corresponding author.
, Joaquim Polido-Pereira
Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
Article information
Full Text
Download PDF
Figures (2)
Full Text

A 40-year-old man with a history of binge drinking and childhood right wrist fracture presented with acute pain, oedema and functional impotence of the right wrist. On physical examination, erythema and oedema of the distal forearm and wrist, and pain elicited by wrist pronation/supination were noted.

Ultrasound examination revealed distal radio-ulnar synovitis, a hyperechoic band within the distal cubital cartilage, and several hyperechoic spots of the triangular fibrocartilage complex (Fig. 1), compatible with calcium pyrophosphate dihydrate (CPP) crystal deposition (CPPD).

Fig. 1.

Ultrasound images of the right wrist. (A) Longitudinal view of the distal ulna, with grey-scale grade 2 synovitis of the distal radio-ulnar joint (asterisk). (B) Transverse view of the distal radio-ulnar joint, with an intrahyaline hyperechoic band parallel to the surface of the distal ulnar cartilage (arrows). (C) Several hyperechoic spots with a “punctate pattern” of the triangular fibrocartilage complex (arrow heads). L – lunate; R – radium; U – ulna.


Plain radiography showed radio-carpal joint space narrowing, subchondral sclerosis of the joint margins, and linear calcifications of the distal radio-ulnar and radio-carpal joints (Fig. 2).

Fig. 2.

Radiography images of the wrists. (A) Anteroposterior projection, with radio-carpal joint space narrowing and subchondral sclerosis of the radium of the right wrist. (B) Detail of the right wrist, with linear calcifications of the distal radio-ulnar and radio-carpal joints (arrows).


Ultrasound-guided joint aspiration was performed. Polarized microscopy of the synovial fluid showed numerous monosodium urate monohydrate (MU) and rare CPP crystals. The patient's uric acid level was 9.1mg/dL. No other metabolic abnormalities were noted. Treatment with colchicine ensured rapid symptom relief and urate-lowering therapy with allopurinol was started four weeks later.

Up to 2.5% of patients with crystal induced arthritis may have coexistent CPP and MU crystals.1 The identification of characteristic birefringent crystals remains essential for the diagnosis of CPPD or gout.2,3 Ultrasonography is a valuable tool for performing guided intra or periarticular diagnostic and therapeutic injections.4 Likewise, growing evidence on its utility in identifying crystal deposits has led to the incorporation of ultrasound findings in CPPD and gout classification criteria.2,3 In gout, the deposits appear as an irregular hyperechoic enhancement over the surface of the hyaline cartilage – the double-contour sign.3 In CPPD, the hyperechoic deposits are of variable shape and typically localized within the fibrocartilage or hyaline cartilage (parallel to the surface of the cartilage).5 Moreover, ultrasonography showed higher sensitivity than radiography and similar accuracy to synovial fluid analysis for detecting CPPD.6,7

Conflicts of interest

The authors declare they have no conflicts of interest.

E.L. Heselden, A.J. Freemon.
Synovial fluid findings and demographic analysis of patient with coexistent intra-articular monosodium urate and calcium pyrophosphate crystals.
J Clin Rheumatol, 22 (2016), pp. 68-70
W. Zhang, M. Doherty, T. Bardin, V. Barskova, P.-A. Guerne, T.L. Jansen, et al.
European League Against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: Terminology and diagnosis.
Ann Rheum Dis, 70 (2011), pp. 563-570
T. Neogi, T.L. Jansen, N. Dalbeth, J. Fransen, H.R. Schumacher, D. Berendsen, et al.
2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.
Ann Rheum Dis, 74 (2015), pp. 1789-1798
J.M. Koski, H.B. Hammer.
Ultrasound-guided procedures: techniques and usefulness in controlling inflammation and disease progression.
Rheumatology (Oxford), 51 (2012), pp. vii31-vii35
G. Filippou, A. Adinolfi, A. Iagnocco, E. Filippucci, M.A. Cimmino, I. Bertoldi, et al.
Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis.
Osteoarthr Cartil, 24 (2016), pp. 973-981
M. Forien, A. Combier, A. Gardette, E. Palazzo, P. Dieudé, S. Ottaviani.
Comparison of ultrasonography and radiography of the wrist for diagnosis of calcium pyrophosphate deposition.
G. Filippou, A. Adinolfi, M.A. Cimmino, C.A. Scirè, S. Carta, S. Lorenzini, et al.
Diagnostic accuracy of ultrasound, conventional radiography and synovial fluid analysis in the diagnosis of calcium pyrophosphate dihydrate crystal deposition disease.
Clin Exp Rheumatol, 34 (2016), pp. 254-260
Copyright © 2017. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Reumatología Clínica (English Edition)

Subscribe to our newsletter

Article options
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?