clinical

2. CRYSTALS DEPOSITION
DISORDERS
Brig.Naveed Hussain Syed
HOD Surgery Department
CMH Bahawalpur

3. TYPES
• CALCIUM PYROPHOSPHATE DIHYDRATE
ARTHROPATHY
• BASIC CALCIUM PHOSPHATE CRYSTAL DEPOSITION
DISEASE
• GOUT

4. GOUT

5. What is gout?
Gout is a common form of inflammatory arthritis
that is very painful. It usually affects one joint at a
time (often the big toe joint). There are times when
symptoms get worse, known as flares, and times
when there are no symptoms, known as remission.

6. STAGES OF GOUT

7. CLINICAL FEATURES

8. PATHOGENESIS

9. FACTORS PREDISPOSING TO
HYPERURICAEMIA

10. DIFFERENTIAL DIAGNOSIS
1.Pseudogout
2.Reiter arthritis
3.Infection
4.Rheumatoid arthritis

11. LABORATORY INVESTIGATION CMH
BWP
CIMS
1. Joint fluid test. joint. Urate crystals may be
visible when the fluid is examined under a
microscope.
2. Blood test. .
3. X-ray imaging. Joint X-rays can be helpful to
rule out other causes of joint inflammation.
4. Ultrasound. This test uses sound waves to
detect urate crystals in joints or in tophi.
5. Dual-energy computerized tomography
(DECT). This test combines X-ray images taken
from many different angles to visualize urate
crystals in joints.

12. RADIOGRAPHIC STUDY
1. During the acute attack x-rays show only soft-tissu
swelling.
2. Chronic gout may result in joint space narrowing
and secondary osteoarthritis.
3. Tophi appear as characteristic punched-out ‘cysts’

13. FOOD TO BE AVOIDED CMH
BWP

14. TREATMENT CMH
BWP
CIMS

15. CALCIUM PYROPHOSPHATE
DIHYDRATE ARTHROPATHY
(PSEUDOGOUT)

16. CPPD CMH
BWP
‘CPPD deposition’ encompasses three overlapping
conditions:
(1) chondrocalcinosis – the appearance of calcific
material in articular cartilage and menisci;
(2) pseudogout – a crystal-induced synovitis; and
(3) chronic pyrophosphate arthropathy – a type of
degenerative joint disease.

17. WHAT IS PSEUDOGOUT? CMH
BWP
Pseudogout (SOO-doe-gout) is a form of arthritis
characterized by sudden, painful swelling in one or
more of the joints. Episodes can last for days or
weeks. Pseudogout is formally known as calcium
pyrophosphate deposition disease or CPPD

18. GOUT VS PSEDOGOUT

19. CLINICAL MANIFESTATIONS CMH
BWP
The CPPD disease encompasses a variety of clinical
manifestations:
1. Asymptomatic to gout-like symptoms
(pseudogout),
2. Rheumatoid arthritis-like symptoms (pseudo-
rheumatoid arthritis), and
3. Osteoarthritis-like symptoms (pseudo-
osteoarthritis)

20. DIAGNOSIS CMH
BWP
1. Joint fluid test..
2. Blood test. .
3. X-ray imaging
X-rays may show signs of chondrocalcinosis,
and the diagnosis can be confirmed by finding positive
birefringent crystals in the synovial fluid.

21. TREATMENT CMH
BWP
The treatment of pseudogout is the same as that of
acute gout:
• rest and high-dosage anti-inflammatory therapy.
• joint aspiration
• intra-articular corticosteroid injection is the
treatment of choice

22. BASIC CALCIUM PHOSPHATE
CRYSTAL DEPOSITION DISEASE

23. CMH
BWP
Basic calcium phosphate (BCP) is a normal component of bone
mineral, in the form of calcium hydrox crystals. It also occurs
abnormally in dead or damaged tissue.
Most common cause of BCP crystal deposition in and around
Joints is local tissue damage – strained or torn ligaments,
tendon attrition and cartilage damage or degeneration.
BASIC CALCIUM PHOSPHATE
CRYSTAL DEPOSITION DISEASE

24. CMH
BWP
Two clinical syndromes are associated with BCP
crystals deposition:
(1) an acute or subacute peri-arthritis;
(2) a chronic rapidly destructive arthritis.
Clinical features

25. CMH
BWP
Milwaukee shoulder
Milwaukee shoulder syndrome is a rare and destructive form of
arthropathy that mainly affects elderly women. It is characterised by intra-
articular or periarticular hydroxyapatite crystals and rapid destruction of the
rotator cuff and the glenohumeral joint

26. CMH
BWP
DIAGNOSIS
Synovial fluid examination
may reveal high counts of polymorphonuclear
leucocytes, but this hardly serves
to distinguish the condition from other types of sub-
acute synovitis. BCP crystals are too small to be seen
by light microscopy but can be identified by electron
probe or transmission electron microscopy.
X-rays
With peri-arthritis, calcification may be seen in ten-
dons or ligaments close to the joint, most commonly
in the rotator cuff around the shoulder.

27. Acute calcification of supraspinatus
(a) Dense mass in the tendon.
(b) Following the ‘reaction’ some calcium
has escaped into the subdeltoid bursa.
CMH
BWP
X-ray
(a) Knee joint exposed at operation.
The articular surface is severely
eroded.
(b) Fragments of meniscus. Note the
white crystalline material on the
large meniscal fragment.

28. CMH
BWP
TREATMENT
Acute peri-arthritis should be treated by
• rest
• non-steroidal anti-inflammatory drugs.
• local injection of corticosteroids;
Erosive arthritis is treated like osteoarthritis.

29. CMH
BWP
Thank you