Crystalline Arthropathy of the Hand

The attack. Severe joint pain begins suddenly, often overnight, and wakes the patient. It is monoarticular at first, although recurrent attacks can be polyarticular. The joint is red, hot and swollen, and so exquisitely tender that the patient cannot tolerate touch or even the bedsheets. Without treatment it is self-limited and resolves in 7-10 days.

In the hand. An affected wrist, MCP, PIP or DIP joint is swollen and erythematous, and pain reduces its range of movement.

Triggers. Ask about each in the history:

• An alcohol binge, particularly beer
• Dehydration
• Acute illness or surgery
• Starting allopurinol, which causes a paradoxical flare

Examination. The skin over the joint is red, oedematous, shiny and tense, and chronic cases may have visible tophi. Tenderness is marked enough that the patient withdraws; the joint is warm with an effusion, and pain severely limits movement. Septic arthritis is the differential that must be ruled out, by joint aspiration.

Tophaceous gout is the chronic phase, defined by tophus deposits of aggregated urate crystals. Tophi are firm, irregular nodules in and around joints, tendons and soft tissues, and chalky white material may drain through the skin, which is pathognomonic. The chronic arthropathy is erosive, with joint destruction and deformity: ulnar drift that mimics rheumatoid arthritis, and fixed contractures.

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Complications. Each follows directly from the tophus, and each has an operation, set out under Surgical Management:

• Carpal tunnel syndrome - tophus in the carpal tunnel compresses the median nerve. It is the most common hand surgical indication in tophaceous gout
• Tendon rupture - tophus weakens an extensor or flexor tendon
• Skin ulceration - tophus erodes through the skin and drains chalky material
• Joint destruction - erosive arthritis and bone destruction

Examination. Look for firm subcutaneous nodules, draining sinuses with a chalky white discharge, and joint deformity (ulnar drift, swan-neck). The tophi are firm and non-tender unless acutely inflamed, and may feel gritty or crunchy.

The nerves. Test the median nerve with Tinel's test at the wrist and Phalen's test, and look for thenar atrophy. Olecranon tophi may bring cubital tunnel symptoms from the ulnar nerve.

Acute pseudogout. The attack resembles acute gout, with sudden pain, swelling and erythema, but is typically less dramatic and not as exquisitely tender. It is self-limited over days to weeks. Illness, surgery, trauma and IV fluids (dilutional hypomagnesaemia) trigger it.

Chronic CPPD arthropathy. A chronic arthritis resembling osteoarthritis, with wrist pain, stiffness and crepitus and a progressive loss of movement, and there may be acute-on-chronic flares. At the wrist, radiocarpal and midcarpal arthritis accompany the chondrocalcinosis described under Investigations.

Examination. There is joint-line tenderness at the wrist, reduced flexion-extension and supination-pronation, crepitus with motion, and an effusion during acute flares. The differential is a SLAC (scapholunate advanced collapse) wrist, and the two can coexist.

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The aim is to reduce inflammation and pain rapidly. The first-line drugs:

• NSAIDs - indomethacin 50mg three times daily or naproxen 500mg twice daily, started immediately at diagnosis and continued until the attack resolves (7-10 days). Renal impairment, a history of GI bleeding and anticoagulation contraindicate them
• Colchicine - the low-dose regimen is 1.2mg as a loading dose, 0.6mg an hour later, then 0.6mg daily. It is effective if started early, within 24-48 hours. Diarrhoea and GI upset are dose-dependent, and severe renal or hepatic impairment contraindicates it
• Corticosteroids - used if NSAIDs or colchicine are contraindicated. Intra-articular triamcinolone 10-40mg if the attack is monoarticular and septic arthritis has been ruled out; oral prednisone 30-40mg daily for 5 days, then a taper; IM or IV methylprednisolone for hospitalised patients unable to take oral medication

Supportive care. Rest and elevate the joint, apply ice, and avoid weight-bearing if the attack is in the lower limb. Aspirating the joint relieves pain as well as confirming the diagnosis.

Do not start urate-lowering therapy during an attack. Starting allopurinol or febuxostat in the acute attack worsens the flare; wait until it has resolved, 2-4 weeks.

Indications. Chronic urate-lowering therapy (ULT) is indicated for:

• Recurrent attacks, more than 2 a year
• Tophaceous gout
• Chronic kidney disease
• Uric acid nephrolithiasis
• Chronic arthropathy

Treating asymptomatic hyperuricaemia to prevent crystal arthropathy is not supported by current guidelines.

The target is a serum uric acid less than 6 mg/dL, ideally less than 5 mg/dL in tophaceous gout.

Allopurinol is first line. A xanthine oxidase inhibitor that blocks uric acid production, it starts at 100mg daily and is titrated every 2-4 weeks to the target uric acid; maintenance is typically 300mg daily and can go up to 800mg. Its side effects are rash (2-5%), hepatotoxicity and the rare but serious allopurinol hypersensitivity syndrome (DRESS). Monitor uric acid, liver function and renal function.

Febuxostat is the alternative: a non-purine xanthine oxidase inhibitor, more potent than allopurinol, at 40-80mg daily. It is used if allopurinol is not tolerated or in renal impairment, although the 2020 ACR guideline (see Evidence Base) keeps allopurinol first line even in moderate-to-severe chronic kidney disease.

Febuxostat and the heart. The CARES trial signalled increased cardiovascular and all-cause mortality. The larger FAST trial (n=6128) then found febuxostat non-inferior to allopurinol for major cardiovascular events (HR 0.85), and guidelines now permit its use with shared decision-making in those with cardiovascular disease. The discordance between the trials (open-label design, differing discontinuation rates, populations) leaves residual uncertainty, and febuxostat is still used cautiously in established cardiovascular disease.

Probenecid is a uricosuric that increases renal excretion of uric acid, for the underexcretor phenotype. It is contraindicated in chronic kidney disease (eGFR less than 50) and with uric acid stones.

Pegloticase is a recombinant uricase, converting uric acid to allantoin, given by IV infusion biweekly. It is very effective but carries a risk of infusion reactions and anaphylaxis, and is reserved for severe tophaceous gout unresponsive to oral ULT.

Covering the start. Starting allopurinol can trigger acute flares by mobilising urate, so co-prescribe colchicine 0.6mg daily or a low-dose NSAID for the first 3-6 months of ULT.

Lifestyle. Limit alcohol, especially beer; avoid purine-rich foods (red meat, organ meats, shellfish); keep hydrated; lose weight if obese.

Acute pseudogout is treated with the same drugs as acute gout: NSAIDs, colchicine, corticosteroids. Aspiration is both diagnostic and therapeutic, relieving the pressure in the joint.

Chronic CPPD arthropathy has no disease-modifying therapy: unlike gout, no medication dissolves calcium pyrophosphate. Management is symptomatic, with NSAIDs and paracetamol for pain, and any underlying metabolic disorder (hyperparathyroidism, haemochromatosis) is treated.

Prophylaxis. In patients with recurrent attacks, low-dose colchicine 0.6mg daily can reduce the frequency of pseudogout flares. Surgery is reserved for severe degenerative wrist arthritis and is described under Surgical Management.

Gout. The indications, each with its operation:

CPPD is usually managed without surgery. Severe wrist arthritis is the exception, covered under Arthritis Surgery.

Medical control first. Optimise medical management, ULT in gout, before elective surgery; perioperative uric acid control reduces wound complications. The conventional teaching is a serum urate under 6 mg/dL for 3-6 months before elective tophus excision. Severe carpal tunnel syndrome with motor signs, or an ulcerated or infected tophus, mandates earlier surgery.

The evidence behind the wait. No high-level evidence defines the exact urate threshold or duration that minimises wound complications; the practice is extrapolated from case series.

Carpal tunnel syndrome develops in 5-10% of patients with tophaceous gout. The symptoms are the classic ones, numbness in the thumb, index and middle fingers and nocturnal pain; there may be palpable masses in the palm or wrist, and thenar atrophy in severe cases.

Technique. A standard open release, with the tophi excised:

1. Standard carpal tunnel incision, curved or longitudinal
2. Divide the transverse carpal ligament completely
3. Identify the tophi, chalky white deposits around the median nerve and flexor tendons
4. Excise them carefully. Dissect the tophi off the median nerve, to which they may be adherent, with a gentle technique; remove them from the flexor tendon sheaths; debulk extensively while protecting the nerve and tendons
5. Inspect the median nerve to ensure complete decompression
6. Close the skin only. Closing the ligament would recompress the nerve

What makes it harder. Tophi may be extensively infiltrative, demanding a more extensive dissection than a standard release, and the median nerve may be encased in tophus and need meticulous dissection. An extended incision proximally may be needed if the tophi are extensive. Send the tophus for pathology, which confirms urate crystals.

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After surgery. A soft dressing, immediate finger range of motion and early movement to prevent adhesions, with ULT continued perioperatively. Wound healing may be delayed, as gout impairs healing.

Outcomes. Symptoms improve in 80-90%. Recurrence is higher than after release for standard carpal tunnel syndrome, 5-10% against less than 2%, and its risk factors are poor uric acid control and incomplete tophus excision.

Before surgery. Bring the uric acid to target with allopurinol or febuxostat, as set out under Indications. Counsel the patient that tophaceous gout impairs wound healing, and continue ULT perioperatively: do not stop allopurinol.

Approach. A direct incision over the tophus. Avoid a tourniquet if possible, as it impairs visualisation of the tophus's extent.

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Excision. The steps:

1. Incise the skin and subcutaneous tissue and identify the tophus, chalky white deposits
2. Dissect the tophus carefully from the surrounding structures. Tophi infiltrate tendons, so excise the tophus but preserve the tendon if possible; dissect it off nerves, to which it may be adherent; open the joint if needed to remove intra-articular tophi
3. Debulk extensively, removing all visible tophus material
4. Irrigate copiously to remove all urate crystal debris
5. Assess the structures: tendon integrity and nerve function

How much to excise. Whether to debulk all tophus material aggressively, at the risk of tendon or nerve injury and large soft-tissue defects, or to perform a conservative decompression remains debated. Some series report excellent function with en masse excision and no recurrence; others favour limited removal, relying on ULT to resolve residual deposits over time.

Closure. Chosen by the state of the skin and the wound:

• Primary closure if the skin is viable and the closure tension-free
• Skin graft or flap if the skin is compromised or necrotic, or the defect large
• Delayed closure if the wound is contaminated or the dissection extensive

Wound care. Keep the wound clean and dry, and monitor for dehiscence and for the early signs of infection, increasing erythema and drainage.

How tendons fail. Tophaceous material infiltrates the tendon substance and the tenosynovium as well as pressing on the tendon from outside. Failure is therefore attritional and infiltrative, unlike a clean traumatic laceration.

Extensor tendons over the dorsal hand and wrist are the classic site. Chalky infiltration of the tendon and its paratenon sometimes presents as a dorsal mass, or as a sudden loss of active finger extension after trivial effort.

Flexor tendons are involved within the digital sheaths and the carpal tunnel. Tophi reduce glide, producing gouty flexor tenosynovitis, triggering or reduced excursion, and extensive carpal tunnel deposits both compress the median nerve and tether the flexors.

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Rupture or nerve palsy. Loss of extension can mimic the Vaughan-Jackson attritional extensor ruptures of rheumatoid disease or a posterior interosseous nerve palsy. The tenodesis test (no passive tenodesis extension when the tendon is ruptured), the absence of a correctable deficit, and visible or palpable tophi point to a mechanical rupture rather than a nerve palsy. The detailed management of rheumatoid extensor ruptures is covered in the rheumatoid hand and wrist topic.

Reconstruction. Debulk the infiltrating tophus while preserving every intact tendon fibre possible, and send tissue for histology. The reconstruction is then graded by tissue loss:

• Partial infiltration, with the substance largely intact - debride the tophus and tubularise or repair directly
• Complete loss with a healthy bed - tendon graft (e.g. palmaris longus) or tendon transfer (for isolated extensor loss, an EIP-type transfer) to restore the lost motor
• Poor bed, active drainage or multiple ruptures - staged reconstruction (silicone rod, then grafting) once urate is controlled and the wound is quiescent

No standard algorithm. The optimal reconstruction after tophus-related rupture, primary repair, graft or transfer, is not standardised, so the choice is individualised to the defect, the tendon bed and the patient's demands. The Doscher hand series (see Evidence Base) is directly relevant: en masse excision and curettage in urate-controlled patients restored tendon excursion and joint mobility with no recurrence over follow-up to fifteen years, reinforcing that meticulous excision plus sustained urate-lowering therapy, not excision alone, salvages tendon function.

Indications. Severe joint destruction, or pain refractory to medical management. Treat it as post-traumatic or degenerative arthritis: optimise medical therapy first, then choose arthroplasty or fusion by the joint, the patient's age and their functional demands.

Gout usually affects the wrist, MCP and PIP joints in an erosive pattern. The options are arthroplasty (silicone MCP arthroplasty) or arthrodesis (wrist or PIP fusion).

CPPD arthritis is most common at the wrist, and the options are:

• Proximal row carpectomy - radiocarpal CPPD arthritis with a preserved capitate
• Total wrist arthrodesis - pancarpal arthritis
• Total wrist arthroplasty - preserves motion, at a higher complication risk