A case of systemic lupus erythematosus associated with trigger wrist

Abstract

A 54-year-old woman complained of a painful, swollen, and clicking left wrist for 1 year. She had an 8-year history of systemic lupus erythematosus (SLE), treated with oral prednisolone. Flexion and extension of all fingers were difficult to initiate on wrist extension, and movement was accompanied by a palpable click at the wrist. Magnetic resonance imaging (MRI) and tenography revealed the expanded sheath of the flexor tendons and well-defined round free bodies known as rice bodies. Synovectomy and excision of rice bodies resulted in complete disappearance of swelling and triggering of the wrist.A 54-year-old, right-handed woman presented with a complaint of a painful, swollen, and clicking left wrist present for 1 year. She had an 8-year history of systemic lupus erythematosus (SLE) and fulfilled five criteria of the ACR classification 1 ; i.e., malar rash, discoid rash, oral ulcers, hemolytic anemia, and antinuclear antibody. She was treated with oral administration of corticosteroid and controlled with medication of 5 mg/day prednisolone. She had undergone total hip arthroplasty and total knee arthroplasty for steroid-induced osteonecrosis of her left femoral head and right medial femoral condyle, respectively. She had been advised to walk with a T-cane in her left hand. Swelling and triggering of her left hand had been present for 1 year. On examination, there was a slight synovial thickening over the palmar aspect of the wrist. It was difficult to initiate flexion and extension of all fingers on wrist extension, and movement was accompanied by a palpable click at the wrist. There were no symptoms or signs of median nerve compression, and there was no deformity in her fingers or wrist.X-ray examinations revealed slight scapholunate dissociation and atrophic changes of the carpus. Plain and enhanced magnetic resonance imaging (MRI) showed diffuse synovial thickening around the flexor tendons (Fig. 1). Tenography revealed the expanded sheath of the flexor tendons, and well-defined round free bodies were visible in the sheath. These free bodies moved proximally and caused the trigger on finger flexion (Fig. 2).Surgical exploration of the carpal tunnel showed a grossly thickened and congested synovial flexor sheath. There was no edematous alteration in the median nerve. All flexor tendons were surrounded by a hypertrophic synovial cuff to which were attached many nodular rice bodies, i.e., 1 ϫ 0.5 cm of gross, yellow, soft mass (Fig. 3). Carpal tunnel decompression was completed, the rice bodies were excised, and synovectomy was carried out. The intraarticular lesions were not examined further because they were not thought to be concerned with the triggering phenomenon. Histological examination of the excised synovial tissue showed hyperplastic synovium with lymphocyte infiltration. The rice bodies were noted to consist of dense fibrinous material.One year postoperatively, the patient remains free of pain and swelling and triggering has disappeared, although there is some remaining limitation of wrist movement....