In this feature, AAOS Now publishes a series of images, challenging readers to diagnose the condition depicted. The images for this month’s challenge were submitted by Waldo Floyd III, MD, and Charles E. Hancock, MD, who provide the following information:

Despite increasing bilateral wrist swelling, a 43-year-old man continued to do significant manual labor. The right wrist swelling became massive, and he sought medical evaluation. His physical examination revealed very significant bilateral wrist swelling and limitation of motion, but without either erythema or significant pain. Joint symptoms were limited to his wrists.

Erythrocyte sedimentation rate, rheumatoid factor, anti-nuclear antibody, and C-reactive protein were normal. Anteroposterior (AP) and lateral radiographs of both wrists are shown. What’s your diagnosis?

Find the answer in the online version of this article, view below.

Do you have a challenging case you’d like to submit for publication? E-mail a short case description and any accompanying images to aaoscomm@aaos.org

ANSWER:
Further questioning revealed that the patient had received an early childhood cerebrospinal shunt. Synovial biopsy of the right wrist demonstrated normal synovial fluid and bone fragments. The right wrist radiographs were characterized by the four Ds of Charcot's arthropathy: deformity, destruction, debris, and density. The left wrist radiographs showed bone fragmentation and radio-density consistent with early neuropathic joint changes. Due to the frequent association of upper extremity neuropathic joints and syringomyelia, cervical magnetic resonance imaging was done, revealing a large syrinx.
Diagnosis: Syringomyelia