GOUT IN THE HAND


What is gout?

Gout is classified as a crystalline arthropathy, which means that the problem is a deposition of crystals. In this case, the culprit is sodium urate crystals. The crystals are deposited in the joint lining and joint fluid secondary to raised uric acid levels (hyperuricaemia) in the blood. There are many causes for raised uric acid levels: The normal process of breaking down blood cells is a cascade of multiple enzymes, and a deficiency in any of these enzymes can precipitate the increase of some of these products. In gout, there is an increase of uric acid that cannot be reduced to a chemical structure that can be excreted by the urine.

Gout usually affects middle-aged men (40-60 years). The common presentation is a painful big toe (called a podagra) causing significant pain that can bring life to a standstill, literally. Gout can also affect the hand, and the presentation is usually a painful red and swollen joint, with a lump on the finger. The onset is sudden and usually very intense.

What are the related symptoms of gout?

Most gout sufferers have multiple flare-ups. In acute disease, the joints become swollen with masses called "tophi". Surgical excision of these masses reveals a toothpaste-like white material. Some other symptoms of gout include severe pain and tenderness on the affected joint. The joints skin may also feel hot and tight with limited range of motion on the affected joint. In some cases, you may also experience nausea, loss of appetite and slight fever.

The diagnosis is usually made by a combination of the clinical picture and the demonstration of raised uric acid levels in the blood. Joints can be aspirated, and the crystals can be seen under polarised microscopes where they exhibit a negative birefringence.

How is gout treated?

The management of gout is usually with anti-inflammatories. Colchicine is a common drug that is used to suppress the inflammation acutely. Furthermore, a hand specialist may recommend diet control, lifestyle modification and certain drugs (Probenecid or Zyloprim) to help prevent the raised uric acid levels by


PSEUDOGOUT


One of the differential diagnoses of a painful wrist in middle-aged men is pseudogout.

Pseudogout presents very similarly to gout, with swelling and redness of especially the wrist. The key difference is that the uric acid level (which is raised in gout) is normal. In pseudogout, the precipitating culprit is calcium-pyrophosphate. This precipitates as crystals (rod-shaped birefringent) in the cartilage of the wrist, especially on the ulnar sided TFCC (triangular fibrocartilage complex).

The diagnosis is often made by arthroscopic biopsies when an infection is suspected. Treatment is conservative with anti-inflammatories and rest.

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