Wrist pain and swelling

Bilateral wrist pain with associated swelling consistent with synovitis pointed to an inflammatory arthritis confirmed by x-ray imaging. An elevated erythrocyte sedimentation rate (109 mm/hr), rheumatoid factor (314 IU/mL), and cyclic citrullinated peptide (34.5 EU/mL) confirmed the diagnosis of rheumatoid arthritis (RA). Hepatitis and tuberculosis screens were negative and uric acid was normal.

The patient’s radiographic imaging of the wrists revealed mild-to-moderate narrowing of the radiocarpal and midcarpal joints, multiple scattered cyst-like and erosive changes throughout, and mild-to-moderate soft tissue edema. These findings were consistent with a diagnosis of RA. Additionally, the radiographs showed cortical irregularity of the proximal ulnar aspect of the lunate, consistent with ulnar abutment syndrome, a degenerative condition in which the ulnar head abuts the triangular fibrocartilage complex and ulnar-sided carpal bones.

Some of the first changes that can be observed radiographically in RA include soft tissue swelling and periarticular osteopenia.¹ As the disease progresses, bony erosions, especially in the metacarpophalangeal and proximal interphalangeal joints, can be observed. Additional findings with active disease include joint space narrowing and deformities, such as joint subluxation. Erosions of cartilage and bone can also occur in some other forms of inflammatory and gouty arthropathies, so it is important to consider differential diagnoses in the case of ambiguous laboratory findings.

The primary disease-modifying antirheumatic drug (DMARD) used for treatment of RA is methotrexate.² DMARDs take weeks to months before there is noticeable improvement and should be used in combination with anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs or glucocorticoids. Response rates to DMARDs decrease over time. In the case of drug resistance, combination therapy (eg, methotrexate plus sulfasalazine and hydroxychloroquine, or methotrexate plus a tumor necrosis factor inhibitor) can be used. For acute flares, patients can undergo intra-articular glucocorticoid injections if a limited number of joints are affected. Widespread flares can be treated with oral glucocorticoids. Severe flares can be treated with pulse intravenous methylprednisolone.

Our patient was referred to Rheumatology for prompt treatment. He was started on DMARD therapy (methotrexate 12.5 mg weekly) with daily folic acid and a plan to increase the methotrexate to 25 mg after the third week of therapy. He was also prescribed oral prednisone to have on hand for flares, and azithromycin to treat possible future infections. Additionally, the patient underwent bilateral steroid wrist injections at the clinic.

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Image courtesy of Daniel Stulberg, MD. Text courtesy of Rachel Ruckman, BS, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Bilateral wrist pain with associated swelling consistent with synovitis pointed to an inflammatory arthritis confirmed by x-ray imaging. An elevated erythrocyte sedimentation rate (109 mm/hr), rheumatoid factor (314 IU/mL), and cyclic citrullinated peptide (34.5 EU/mL) confirmed the diagnosis of rheumatoid arthritis (RA). Hepatitis and tuberculosis screens were negative and uric acid was normal.

The patient’s radiographic imaging of the wrists revealed mild-to-moderate narrowing of the radiocarpal and midcarpal joints, multiple scattered cyst-like and erosive changes throughout, and mild-to-moderate soft tissue edema. These findings were consistent with a diagnosis of RA. Additionally, the radiographs showed cortical irregularity of the proximal ulnar aspect of the lunate, consistent with ulnar abutment syndrome, a degenerative condition in which the ulnar head abuts the triangular fibrocartilage complex and ulnar-sided carpal bones.

Some of the first changes that can be observed radiographically in RA include soft tissue swelling and periarticular osteopenia.¹ As the disease progresses, bony erosions, especially in the metacarpophalangeal and proximal interphalangeal joints, can be observed. Additional findings with active disease include joint space narrowing and deformities, such as joint subluxation. Erosions of cartilage and bone can also occur in some other forms of inflammatory and gouty arthropathies, so it is important to consider differential diagnoses in the case of ambiguous laboratory findings.

The primary disease-modifying antirheumatic drug (DMARD) used for treatment of RA is methotrexate.² DMARDs take weeks to months before there is noticeable improvement and should be used in combination with anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs or glucocorticoids. Response rates to DMARDs decrease over time. In the case of drug resistance, combination therapy (eg, methotrexate plus sulfasalazine and hydroxychloroquine, or methotrexate plus a tumor necrosis factor inhibitor) can be used. For acute flares, patients can undergo intra-articular glucocorticoid injections if a limited number of joints are affected. Widespread flares can be treated with oral glucocorticoids. Severe flares can be treated with pulse intravenous methylprednisolone.

Our patient was referred to Rheumatology for prompt treatment. He was started on DMARD therapy (methotrexate 12.5 mg weekly) with daily folic acid and a plan to increase the methotrexate to 25 mg after the third week of therapy. He was also prescribed oral prednisone to have on hand for flares, and azithromycin to treat possible future infections. Additionally, the patient underwent bilateral steroid wrist injections at the clinic.

‌

Image courtesy of Daniel Stulberg, MD. Text courtesy of Rachel Ruckman, BS, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Bilateral wrist pain with associated swelling consistent with synovitis pointed to an inflammatory arthritis confirmed by x-ray imaging. An elevated erythrocyte sedimentation rate (109 mm/hr), rheumatoid factor (314 IU/mL), and cyclic citrullinated peptide (34.5 EU/mL) confirmed the diagnosis of rheumatoid arthritis (RA). Hepatitis and tuberculosis screens were negative and uric acid was normal.

The patient’s radiographic imaging of the wrists revealed mild-to-moderate narrowing of the radiocarpal and midcarpal joints, multiple scattered cyst-like and erosive changes throughout, and mild-to-moderate soft tissue edema. These findings were consistent with a diagnosis of RA. Additionally, the radiographs showed cortical irregularity of the proximal ulnar aspect of the lunate, consistent with ulnar abutment syndrome, a degenerative condition in which the ulnar head abuts the triangular fibrocartilage complex and ulnar-sided carpal bones.

Some of the first changes that can be observed radiographically in RA include soft tissue swelling and periarticular osteopenia.¹ As the disease progresses, bony erosions, especially in the metacarpophalangeal and proximal interphalangeal joints, can be observed. Additional findings with active disease include joint space narrowing and deformities, such as joint subluxation. Erosions of cartilage and bone can also occur in some other forms of inflammatory and gouty arthropathies, so it is important to consider differential diagnoses in the case of ambiguous laboratory findings.

The primary disease-modifying antirheumatic drug (DMARD) used for treatment of RA is methotrexate.² DMARDs take weeks to months before there is noticeable improvement and should be used in combination with anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs or glucocorticoids. Response rates to DMARDs decrease over time. In the case of drug resistance, combination therapy (eg, methotrexate plus sulfasalazine and hydroxychloroquine, or methotrexate plus a tumor necrosis factor inhibitor) can be used. For acute flares, patients can undergo intra-articular glucocorticoid injections if a limited number of joints are affected. Widespread flares can be treated with oral glucocorticoids. Severe flares can be treated with pulse intravenous methylprednisolone.

Our patient was referred to Rheumatology for prompt treatment. He was started on DMARD therapy (methotrexate 12.5 mg weekly) with daily folic acid and a plan to increase the methotrexate to 25 mg after the third week of therapy. He was also prescribed oral prednisone to have on hand for flares, and azithromycin to treat possible future infections. Additionally, the patient underwent bilateral steroid wrist injections at the clinic.

‌

Image courtesy of Daniel Stulberg, MD. Text courtesy of Rachel Ruckman, BS, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.