History of Present Illness:
A pleasant woman in her mid-90’s presents to the hospital with 2 days of worsening atraumatic left wrist pain. She denies any fever, injury or history of same but she does have to push hard with her hands to get up out of her chair and thinks perhaps she injured it doing this.
Vital Signs & Physical Exam:
She is afebrile and other vital signs are also normal. Physical exam is normal except for left wrist redness, swelling and tenderness
Initial Diagnostic Testing:
- CBC: normal
- Chem-7: normal
- Imaging: see below
What is the LEAST likely diagnosis?
- A) Osteoporosis
- B) Chondrocalcinosis
- C) Pseudogout
- D) Wrist fracture
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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
Emergency Medicine 1-Minute Consult, 5th edition
A-to-Z EM Pharmacopoeia & Antibiotic Guide, NEW 5th edition
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ANSWER:
- A) Osteoporosis – common at this age and seen on x-ray
- B) Chondrocalcinosis – not easily seen but present on x-ray
- C) Pseudogout – this is a classic presentation and there is B) to support it
- D) Wrist fracture – CORRECT: there is no fracture present
1-Minute Consult on this topic: Click HERE and scroll to the MIDDLE of page 291.
CASE CONCLUSION: Tap was dry so CT was ordered to rule out an occult fracture since she had osteoporosis on x-ray. CT showed soft tissue swelling without an effusion but erosions and extensive chondrocalcinosis consistent with pseudogout as well as osteoporosis and severe OA of the first carpometacarpal joint but no fractures
CASE LESSONS: The classic presentation of pseudogout is severe unilateral atraumatic wrist pain in an elderly patient. X-rays may show chondrocalcinosis, especially if a knee x-ray is also done. This is the first case I have had with a dry tap. I have had about 8 other cases with a diagnostic tap.