Disclosures: James E. Gardner, MD: No financial relationships or conflicts of interest

Case Diagnosis: This is a case of a 46-year-old male with a history of renal transplant who presented with persistent left wrist pain and swelling who underwent diagnostic ultrasound evaluation and was subsequently diagnosed and treated for acute gout of the wrist.

Case Description or Program Description: The patient several weeks prior to being seen developed atraumatic left wrist pain and swelling. He was placed on oral prednisone for presumed gout by his nephrologist with temporary relief. Due to recurrence, he was referred to an orthopaedic upper extremity surgeon who noted generalized left wrist swelling and tenderness on exam with no erythema. No wrist range of motion, strength, or sensory deficits were noted. Left x-ray demonstrated diffuse soft tissue swelling, but no definitive osseous abnormalities. He was referred to our clinic to undergo a left wrist ultrasound evaluation.

Setting: Outpatient Musculoskeletal Clinic

Assessment/Results: On ultrasound, there was dorsal radiocarpal joint recess distension with complex fluid. Hyperemia was present on color Doppler. A hyperechoic linear density (double contour sign) was seen overlying the surface of the dorsal radiocarpal joint cartilage. An ultrasound-guided radiocarpal joint arthrocentesis was performed with synovial fluid analysis positive for uric acid crystals. Subsequently, an ultrasound-guided radiocarpal joint steroid injection was performed. 1 week following this injection the patient reported complete relief of his left wrist symptoms.

Discussion (relevance): Reduced uric acid excretion can occur after renal transplantation, leading to gout. The wrist joint as the initial appearance of the condition is rare but can occur. Findings on ultrasound evaluation can be helpful to support the diagnosis of gout, especially the presence of a double contour sign. Ultrasound can also guide wrist joint arthrocentesis for confirmatory synovial fluid analysis and steroid injection for definitive treatment.

Conclusions: Gout is common in renal transplant recipients. Ultrasound is helpful to confirm the diagnosis and guide treatment for a gout flare.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/atraumatic-wrist-swelling-and-pain-in-the-setting-of-a-renal-transplant-a-case-report/