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Invovlement Of Carpal Bones In Gouty Arthritis

*J. Terrence Jose Jerome, , **Balu Sankaran,*** Thirumagal  

**Professor Emeritus, Orthopedics, St Stephen’s Hospital, Tiz Hazari, Tamilnadu, India.

Address for Correspondence

Dr. J.Terrence Jose Jerome, M.B.B,S
Post graduate in orthopedics,
St Stephen’s Hospital, Tiz Hazari,
: 911-09868086916
Fax : 911-23932412


The deposition of gouty tophi in the hand occurs relatively late in the disease. Involvement of carpal bones is nowhere reported in the literature. We present a 40-year-old man with a long duration of gouty arthritis involving the carpal bones.

J.Orthopaedics 2006;3(4)e10


Gouty arthritis has various modalities of presentations in the hand. Metacarpo-phalangeal joints are most commonly involved in gouty arthritis. The differential diagnosis includes Psoriasis, Osteoarthritis, Infection, Calcium pyrophosphate dehydrate de-position of disease (CPPD) and Rheumatoid arthritis. Proper clinical examination, laboratory evaluations, and histological examinations will confirm the diagnosis.

We present a 40-year-old man with gouty arthritis and deposition of tophi over the dorsal aspect of wrist involving the carpal bones.

Case Report

A 40-year-old man, presented to the clinic with complaints of left knee pain. His medical history included 18-year-old history of gouty arthritis and on and off treatment for the same. He used to take non-steroidal anti-inflammatory drugs for occasional pain in both feet. He also took allupurinol along with non-steroidal inflammatory drugs during acute attacks of joint pain and prophylaxis up to the age of 35 years.

On examination of the left knee, there was a no effusion. Knee movements were clinically normal. Multiple small nodules were seen on the dorsum of the left hand with a 2*3 cm large nodule over the base of third metacarpal. They are not warm, not tender, and cystic to firm in consistency and the underlying extensors tendons were free. The skin over the nodules was normal and pinchable. No discharging sinus or ulcer noted.

Multiple tophaceous deposits, grayish discoloration, hallux valgus deformity were noted on the great toe on both sides. A large localized swelling was seen in the retrocalcaneal region of this patient that was cystic in nature, not warm and tender and free from the tendo calcaneus.

Erythrocyte sedimentation rate was 25 mm in the first hour (normal <14). His blood parameters revealed hemoglobin 11.2gms, TLC 7,500cu\mm. Complete blood counts, C-reactive protein, liver function tests, creatinine, electrolytes, and thyroid function test and protein electrophoresis were normal. Tests for anti-nuclear body, rheumatoid factor and HLA- B27 were negative. Serum uric acid was 4.1mgs (Normal 3-7 mgs). Ultrasound KUB was normal. Urine examinations were normal.

Radiograph of the wrist Fig (1) showed, a circular punched-out lytic lesion involving scaphoid, capitate and trapezoid bones. Metacarpals, phalanges were normal. Radiograph of the feet revealed a classic ‘punched-out’ lytic lesion, marginal erosions and an associated overhanging edge at the distal metatarsals.

Straw colored fluid was aspirated from both retrocalcaneal region and left wrist dorsal swelling. Microscopic examination and culture for aerobic, anerobic, acid fast, and fungal organisms were negative. Rhomboidal shaped urate crystals were seen with few RBC’s in between Fig (2). Pus cells were not seen.

He was treated with non-steroidal anti-inflammatory drugs, protected weight bearing and physiotherapy. Four weeks after the visit, he had improved, with decreased pain and increased movement.

Discussion :

Deposition of gouty tophi in the hand occurs relatively late in the disease and is uncommon with good medical management4. Radiographic manifestations of gouty arthritis may precede symptoms in up to 25% of patients and may precede deposition of gouty tophi in up to 42% 5.

Gouty arthritis has various modalities of presentations in the hand. This includes acute suppurative flexor tenosynovitis4,6, carpal tunnel syndrome4,7, and a localized painful mass in the mid-palm1,2,3, tophi over the dorsal aspect of the interphalangeal and metacarpophalangeal joints1,2,3. Neglected cases can produce intratendinous infiltration, flexion contractures, tendon rupture, and skin ulceration in extreme cases1,6.

Gouty tenosynovitis in the hand can be present without tophi or previous involvement of upper extremity6. Often called “the imitator”, gout may masquerade as septic arthritis, rheumatoid arthritis or neoplasm, and the diagnosis is often delayed by weeks or months.

Gout can rarely coexist with rheumatoid arthritis,8 but it is perhaps more frequently misdiagnosed as rheumatoid arthritis because of its proliferative synovitis6  and because 10% to 20% of patients with rheumatoid arthritis have elevated uric acid levels.

The early radiological signs of gout are joint effusion and periarticular edema, caused by the deposition of the non-opaque crystals within the synovial and cartilaginous tissues1,2,3. Radiographic examination eventually reveals a classic ‘punched-out’ lytic lesion with an associated overhanging edge at the distal metatarsals2. Multiple marginal erosions and decreased joint space are seen at several metacarpal-phalangeal joints. These erosions contain sclerotic borders5.

Osteopenia and the loss of joint space are usually not seen until advanced disease stages2. Additionally, the advanced stage is also characterized by joint destruction and severe deformities. Proliferative osseous change, intraosseous cysts, chondrocalcinosis and olecranon bursitis can occasionally be seen in the patients with gout1.

 The diagnosis of gout should not be based on laboratory values alone. Joint or tenosynovial aspiration, Gram stain, and examination under polarized light is 85% sensitive for the diagnosis of gout and may be helpful in differentiating acute gouty tenosynovitis from rheumatoid arthritis or infection3.

The asymmetry and lack of joint space narrowing not seen until advance stages allow differentiation from other similar-appearing disorders (e.g., Psoriasis, Osteoarthritis, Infection, and Rheumatoid arthritis). Calcium pyrophosphate dehydrate de-position disease (CPPD) can have symptoms resembling that of gout and can also occur concomitantly in up to 40% of patients with gout9.

Our patient who was on long duration of treatment for gouty arthritis presented to our clinic with non-specific knee pain and an incidental radiological evaluation of left hand showed the involvement of carpal bones.

 Our review of literature did not show carpal involvement in gouty arthritis. Our patient had multiple tophi deposition on the dorsum of hand. Histological examination demonstrated urate crystals from the aspirate of hand and retrocalcaneal region and confirmed the carpal involvement.


Gouty arthritis can also occur in carpal bones. It can occur alone or along with or without the associated findings. One should always have a high index of suspicion. Systematic, good clinical examination and proper radiographs should be carried out. Histology confirms the diagnosis. Carpal involvement in gouty arthritis should also be kept in the differential diagnosis in any case of unusual lytic lesions in carpal bones.

Gouty arthritis has a various presentations in hand. They include acute tenosynovitis, carpal tunnel syndrome, tophi deposition in palm, punched-out lytic lesions; metacarpals are usually involved. Carpal bones are not involved. This case showed the involvement of carpal bone. One should be careful in interpreting hand radiographs. A systematic clinical examination along with radiographs and aspiration cytology confirms the diagnosis.


Reference :

  1. Zayas VM, Calimano MT, Acosta AR, et al. Gout: The radiology and clinical manifestations. Appl Radiol. 2001; 30(11): 15-23
  2. Uri DS, Dalinka MK. Crystal Disease. Radiol Clin North Am.1996; 34:359-364
  3. Becker MA: Clinical aspects of monosodium urate monohydrate crystal deposition disease (gout). Rheum Dis Clin North Am 14:377-394, 1988.
  4. Moore JR, Weiland AJ: Gouty tenosynovitis in the hand. J Hand Surg [Am]10: 291-295, 1985.
  5. Barthelemy CR, Nakayama DA, Carrera GF, et al: Gouty arthritis: Aprospective radiographic evaluation of sixty patients. Skeletol Radiol 11:1-8,1984.
  6. Abrahamsson SO: Gouty tenosynovitis simulating an infection: A casereport. Acta Orthop Scand 58: 282-283,1987.7.  
  7. Janssen T, Rayan GM: Gouty tenosynovitis and compression neuropathy ofthe median nerve. Clin Orthop Mar (216):  203-206,1987.  
  8. Atdjian M, Fernandez-Madrid F: Coexistence of chronic tophaceous goutand rheumatoid arthritis. J Rheumatol 8: 989-992,1981.  
  9. Lagier R, Boivin G, Gerster JC: Carpal tunnel syndrome associated withmixed calcium pyrophosphate dihydrate and apatite crystal deposition intendon synovial sheath. Arthritis Rheum 27: 1190-1195,1984.


This is a peer reviewed paper 

Please cite as :Terrance Jose : Invovlement Of Carpal Bones In Gouty Arthritis

J.Orthopaedics 2006;3(4)e10







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